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r< 



MINOR SURGERY. 



ON 



BANDAGING, 



L 



AND OTHER 



OPERATIONS 



MINOR SURGERY. 






BY 



F. W. SAEGENT, M. D. 




PHILADELPHIA: 
LEA AND BLANCHARD. 

1848. 



Entered, according to the Act of Congress, in the year 1848, 

By Lea & Blanchard, 

In the Clerk's Office of the District Court for the Eastern District of 

Pennsylvania. 



C. SHERMAN, PRINTER, 
19 St. James Street. 



TO 

GEORGE W. NORRIS, M.D. 

SURGEON TO THE PENNSYLVANIA HOSPITAL, 

AS A TRIBUTE OF RESPECT 

FOR HIS PROFESSIONAL AND PERSONAL CHARACTER, 

AND IN ACKNOWLEDGMENT 

OF HIS INSTRUCTIONS AND REPEATED KINDNESS, 

31)is Volume 

IS INSCRIBED 

BY THE AUTHOR. 



PREFACE. 



The object which the author has had in view in the pre- 
paration of the following pages, has been, to present to the 
younger surgeon and to the student, information relative to 
the art of bandaging, and to some other points of import- 
ance in the practice of surgery. These are subjects which 
are but slightly alluded to in systematic courses of lectures, 
or in most of the published treatises on the science ; yet the 
necessity of a familiar acquaintance with them will be 
readily acknowledged by every surgeon of experience. 

In the collection of the materials for this volume, the au- 
thor has availed himself very freely of the knowledge of 
others, as exhibited in books, and of his own opportunities 
in hospitals and in private, of gaining practical acquaint- 
ance with the subjects of which he has treated. He trusts 
that he has not failed in his intention, always to give due 
credit to all from whom he has taken information. Origi- 
nality can scarcely be expected, in a work of this kind, ex- 
cepting perhaps in its composition. 

The book is divided into five parts. Of these, the first 
embraces a description of the implements, if such a term 
be admissible, with which the ordinary duties of the sur- 
geon are accomplished. 

The second treats of the composition and preparation of 



Vlll PREFACE. 

Bandages, of their application to the different regions of 
the body, and of the purposes which they are thus made to 
subserve. 

The third is devoted to the consideration of the appara- 
tus of various kinds, used in the treatment of Fractures. 
In the arrangement of this portion of the volume, the au- 
thor has thought it expedient to give pretty full details, 
showing the indications of treatment in each particular 
case of Fracture, and thereby rendering more manifest the 
adaptation of each bandage, splint, or other dressing, to 
the fulfilment of these requirements. 

The fourth division describes the mechanical means em- 
ployed in the treatment of dislocations, with the mode of 
applying them. 

In the fifth part are detailed at length the methods of 
performing such operations as seem strictly to be included 
in the term " Minor Surgery ;" these are the operations for 
bleeding, general and local ; the modes of effecting counter- 
irritation ; — the methods of arresting hemorrhage ; the 
closure of wounds ; the introduction of the catheter, and 
the administration of injections. A few remarks on the 
mode of relieving pain during operations, and a short ap- 
pendix of useful formulae, close the volume. 

The engraving of the illustrations for most of the sub- 

^/ jects, was entrusted to Mr. Spittall, Prune Street, to whose 

skill the author cheerfully acknowledges his indebtedness, 

as also to Mr. Sherman, for the very commendable manner 

in which the book has been printed. 

Philadelphia, May 1848. 



LIST OF ILLUSTRATIONS 



FIG. PAGE. 

1. Double catheter, ...... 27 

2. Graduated compress, from Cutler, - - 34 

3. Pyramidal, " " " . - - 34 

4. Malta cross, « « - - - 35 

5. Treatment of epididymitis by compression, from Velpeau, - 40 

6. Hays' bandage for retaining dressings, - - .44 

7. " " applied to the leg, ... 44 

8. Arch of hoop, from South, - - - . 54 

9. Apparatus for irrigation, from Velpeau, ... 57 

10. Portable shower-bath, from Thomson, - . - 60 

11. Portable bathing apparatus, from Thomson, 63 

12. Vessel for the hip-bath, «« " - - -65 

13. Machine for rolling bandages, .... 71 

14. Different applications of the roller, from Cutler, > - 73 

15. Mode of making reversed turns, from Velpeau, - - 75 

16. Crossed bandage of the elbow, from Cutler, - - - 75 

17. Recurrent bandage of the head, from Velpeau, - - 86 

18. Four-tailed " of the head, from Cutler, - - - 87 

19. Six-tailed " of the head, from Velpeau, 88 

20. Four-tailed « of the chin, from Cutler, - - -90 

21. Double T « of the nose, « . . 91 

22. Monocle " « » . . _ 93 

23. Invaginated " of the lip, from Smith, - - 93 



X LIST OF ILLUSTRATION'S. 

FI& - PAGE. 

24. Purse of Pibrac for the tongue, from Velpeau, - - * - 94 

25. Flexor bandage of the neck, «• « . 96 

26. Jorg's apparatus for wry-neck, from Cutler, - - - 97 

27. Compressing bandage of the chest, from Velpeau, - 100 

28. Crossed " " " « . . - 101 

30. Compressing " of the abdomen, " " . 10.5 

31. Triangular «' of the groin " " - - . 106 

32. Cruro-inguinal triangle, irom Cutler, ... 106 
33 and 34. Suspensory of the scrotum, from Cutler, - ] 09 

35. Suspensory triangle, from Cutler, - - - 110 

36. Spica bandage of the shoulder, from Velpeau, - - 114 

37. Gauntlet, from Velpeau, - - - - - 116 

38. Demi-gauntlet, from Velpeau, - - - - 116 

39. Spiral bandage of the leg, - 120 

40. Pasteboard splint for the chin, from Cutler, - - - 140 

41. Gibson's bandage for fracture of the lower jaw, from Gibson, 142 

42. Barton's " ■ «... 142 

43. Fox's apparatus for fracture of the clavicle, . - 150 

44. Lonsdale's " " " from Lonsdale, - 151 

45. Velpeau's bandage for fracture of the shoulder, from Velpeau, 156 

46. Lonsdale's " " " acromion, from Lonsdale, 157 

47. Splint for fractures of the humerus, from Lonsdale, - 162 

48. Fracture of humerus, above the condyles, from Cooper, - 165 

49. " " through the condyles, from Lonsdale, 165 

50. Splints for the treatment of this accident, from Cooper, - 167 

51. Mayo's splint for compound fractures, from Lonsdale, - 169 

52. Ante-brachial hyponarthecia, from Cutler, - - 174 

53. Dupuytren's splint for fracture of the radius, from Lonsdale, 175 

54. Oblique fracture of the lower end of the radius, from Fergusson, 176 

55. Treatment of fracture of the olecranon process of the ulna, from 

Cooper, ...... 179 

56. Olecrano-metacarpal cravat, from Cutler, ... 180 



LIST OF ILLUSTRATIONS. 



XI 



FIG. 

57. 

58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 
66. 
67. 
68. 
69. 
70. 
71. 
72. 
73. 
74. 
75. 
76. 
77. 
78. 
79. 
80. 
81. 
82. 
83. 
84. 
85. 
86. 
87. 



Splint for fractures of the bones of the hand, from Lonsdale, 
Doable inclined plane, from Lonsdale, ... 
The same applied, " ... 

Mr. Amesbury's double inclined plane, from Amesbury, 
The same applied, from Amesbury, ... 
Dr. N. R. Smith's splint, from H. H. Smith, 
The long splint of Desault, - 

Gaiter for extension, ..... 

Cravat band for extension, .... 
Boyer's apparatus for fracture of the thigh, from Cutler, - 
Liston's splint " " " from Fergusson, 

Gibson's Hagedorn's apparatus, from Gibson, 
Treatment of fracture of the great trochanter, from Cooper, 
" « of the patella, " " - 

It (( U U It 

Lonsdale's apparatus for the same, from Lonsdale, 

Fracture-box, ..... 

A fractured leg, from Fergusson, ... 

Mr. Liston's splint, double plane, from Fergusson, 

" Pott's fracture" of the fibula, from Lonsdale, 

Dupuytren's treatment of the same, " 

Mode of treatment of fracture of the os calcis, from Lonsdale, 

" " " «■ « from Druitt, 

Dislocation of the lower jaw, from Druitt, ... 
Bandage for treatment of dislocation of clavicle, from Druitt, 
Reduction of dislocation of the humerus, from Cooper, 

II 11 It (« 

Pulleys and staple, from Fergusson, ... 

Reduction of dislocation of the humerus, from Cooper, - 
Reduction of dislocation of phalanx, from Fergusson, 

(( U 41 (C U 

" The clove-hitch," from Fergusson, ... 



PAGE. 

183 
190 
191 
193 
194 
195 
197 
198 
201 
204 
205 
206 
210 
215 
216 
218 
223 
223 
227 
228 
229 
233 
233 
237 
239 
241 
242 
242 
243 
247 
247 
247 



Xll LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

89. Reduction of dislocation of the thumb, from Cooper, - - 248 

90. « « femur, « - - 250 

91. » " " «... 251 

92. « " " «,.'-. 252 

93. « « « »... 253 

94. " " " from Fergusson, - 254 

95. Apparatus for the relief of partial anchylosis, from Mutter, - 259 

96. Disposition of the veins, &c. at the bend of the arm, from Wil- 

son, ....... 262 

97. « « « " Druitt, 262 

98. Position of the lancet in bleeding, from Fergusson, - - 270 

99. Bleeding from the jugular vein and temporal artery, from Vel- 

peau, ....... 275 

100. Forms of the actual cautery irons, from Liston and Mutter, 313 

101. Compression of the brachial artery, from Fergusson, - 315 

102. " of the femora], " « - . 316 

103. The tourniquet, from Fergusson, - 317 

104. " applied to the arm, from Fergusson, - 318 

105. " " « thigh, " - - 318 

106. " " " popliteal region, from Fergusson, 318 

107. Field tourniquet applied to the arm, from Liston and Mutter, 319 

108. The compressor of Dupuytren applied to the thigh, from Liston 

and Mutter, . - - - - - 320 

109. The toothed forceps, from Fergusson, - 321 

110. The tenaculum, .... 323 

111. The sailor's knot, » - - - - 323 

112. The common aneurism needle, from Fergusson, - - 325 

113. Physick's forceps, from Liston and Mutter, - - 326 

114. Mode of plugging the nostrils, " « - - - 327 

115. Belloc's instrument for the same, " 328 

116. The interrupted suture, from Fergusson, - . - 334 

117. The quilled suture, from Druitt, - 336 



LIST OF ILLUSTRATIONS. Xlll 

FI&- PA&E. 

118. Surgeon's needles, from Fergusson, - - - . 336 

119. The hare-lip suture, " - 337 

120. The invaginated bandage for longitudinal wounds, from Cutler, 339 

121. Same applied, from Cutler, - 339 

122. Invaginated bandage for transverse wounds, from Cutler, - 340 

123. Catheters for the male urethra, from Fergusson, - - 345 

124. Introduction of the male catheter, - 346 

125. Obstruction to catheterism from enlarged prostate, from Druitt, 349 

126. Velpeau's mode of securing the catheter in the bladder, from 

Velpeau, ------ 350 

127. Inhalers, from Pereira, - - . - - 363 



TABLE OF CONTENTS. 



PAGE. 

PREFACE, .-.-.. viii 

PART I. 
CHAPTER I. 

ON THE INSTRUMENTS USED IN DRESSING, - 26 

CHAPTER II. 

ON SURGICAL DRESSINGS. 

Lint — Charpie — Cotton — Tow — The Compress — Retractors — The 
Malta Cross — Sponge Tent — Setons — Adhesive Plasters — Soap 
Plaster — Mercurial Plaster — The Poultice — The Water-dressing 
— Lotions — Cerates — Ointments — Liniments — The Sponge, - 29 

CHAPTER III. 

GENERAL RULES FOR DRESSING, 52 

CHAPTER IV. 

ON THE USE OF WATER, . - .55 

SECTION I. 
Irrigation, ... 55 

SECTION II. 
The Douche, - . 57 



XVI CONTENTS. 

SECTION III. 
Bathing. — Water and Vapour Baths, - 61 

SECTION IV. 
On Fumigations, - . .66 

SECTION V. 

On Disinfecting Agents, - 67 

PAKT II. 

ON BANDAGES AND THEIR APPLICATION, - 70 

CHAPTER I. 

SECTION I. 

The Roller, or Simple Bandage. 

Composition and preparation of the Roller — Different modes of ap- 
plication — Circular — Spiral and reversed turns — Crossed — Spica 
and recurrent bandages — Uniting — Dividing — Compressing — 
Expelling — Retaining and Knotted bandages - - - 71 

SECTION II. 
Compound Bandages. 

The T bandage—The Invaginated— The Split, or Tailed— The 

Laced — The Sheath — And the Suspensory bandages, - 78 

SECTION III. 
M. Mayor's System of Bandages, - - 82 



CONTENTS. XVII 

CHAPTER II. 

REGIONAL BANDAGING. 
SECTION I. 

Bandages for the Head and Neck. 

The Recurrent — The T — The Four-tailed — the Six-tailed bandages 
— The Fronto-occipital Triangle — The Knotted — The Four-tailed 
bandage of the Chin — The T-bandage of the Ear — The double 
T-bandage of the Nose — The sheath of the Nose — Bandages for 
the Eyes — The Invaginated bandage of the Lip — The Sheath of 
Pibrac for the Tongue — The Mask for the Face — The Cervical 
Cravat — The flexor bandage of the Neck — Jbrg's flexor of the 
Neck ....... 85 

SECTION II. 
Bandages for the Trunk. 

The Dorso-thoracic Triangle — Circular bandage — The bandage of 
Velpeau — The figure-8 bandage of the shoulders — The Sus- 
pensory of the breast — The triangular cap for the breast — The 
Compressor of the breast — The Straight-jacket — The Body- 
bandage — The triangular coverings for the Sacrum and Pubis — 
The triangular bandage for the Groin — The Cruro-inguinal tri- 
angle — The Spicas of the Groin — The Cruro-inguinal cravat — 
The double T-bandage for the Pelvis — Suspensories of the Scro- 
tum — Bandage for the Penis, .... 98 

SECTION III. 

Bandages for the Upper Extremity. 

The Axillo-clavicular cravats — the figure-8 bandage for the shoulder 
and axilla — Sling for the fore-arm — Triangular bandages for the 
wrist and hand — The Spiral for the arm — The Spica for the arm 
and shoulder — The Spica for the thumb — The Gauntlet — The 
Demi-gauntlet — The cravat bandage for the hand — The perfo- 
rated bandage for the hand, - . _ . Ill 

2* 



XV111 CONTENTS. 

SECTION IV. 

Bandages for the Lower Extremity. 

The Cruro-iliac triangle — The bandage of Scultetus — The eighteen- 
tailed bandage — The invaginated bandages — The figure-8 ban- 
dage for the knee — Weiss's elastic knee-cap — Common elastic 
cap for the knee — Spiral bandages for the lower extremity — 
Baynton's bandage — The laced-stocking — The Gaiter - 117 



PART III. 

BANDAGES AND APPARATUS EMPLOYED IN THE TREATMENT OF FRACTURES. 

CHAPTER I. 

GENERAL CONSIDERATIONS. 

Mode of reparation of fracture — Indications of treatment — " The 
Immovable Apparatus" of Larrey, Seutin, Velpeau, Langier, and 
Dieffenbach — The " Hyponarthecia" of Sauter and Mayor — 
Vehicle for transporting injured persons — Mode of exposing the 
seat of injury — Fracture-beds — Clinical frame — The apparatus 
of Jenks, for raising the patient from the bed, - - 123 

CHAPTER II. 

BANDAGES AND DRESSINGS FOR FRACTURES OF THE BONES OF THE HEAD AND 

TRUNK. 

SECTION I. 

For Fractures of the Bones of the Skull and Face. 

Of the bones of the Cranium — Of the Face — The four-tailed ban- 
dage of the chin, for fractures of the lower jaw — Gibson's and 
Barton's bandages for the same — Mr. Lonsdale's apparatus for 
the same, ------- 139 



CONTENTS. XIX 

SECTION II. 

Bandages for Fractures of the Bones of the Trunk. 

For fractures of the Vertebrae — Of the Ribs and Sternum — Treat- 
ment by compresses and a roller — By lath or pasteboard splints 
— Fractures of the Sternum — Fractures of the bones of the Pelvis 
— Treatment of compound fractures, ... 143 

CHAPTER III. 

APPARATUS AND DRESSINGS FOR FRACTURES OF THE BONES OF THE SHOULDER. 

SECTION I. 

For Fractures of the Clavicle. 

Older methods of treatment — Fox's apparatus — Bandage of Mr. 

Lonsdale — Of Brown — New plan recommended by M. Guillou, 147 

SECTION II. 

For Fractures of the Scapula. 

Fractures of the body and inferior angle — Of the coracoid process 
— Bandage of M. Velpeau — Of the acromion process and neck — 
Mr. Lonsdale's mode of treatment — Other apparatus — Compound 
fractures, - - - - - - - 153 

CHAPTER IV. 

SECTION I. 
For Fractures of the Humerus. 

Fracture of the shaft of the bone — Ordinary mode of treatment — 
Mr. Lonsdale's splint — Fractures of the upper extremity of the 
bone — At the surgical and anatomical neck — Fracture at the 
condyloid extremity — Sir A. Cooper's method of treatment — Mr. 
Mayo's splint for compound fractures of this portion of the bone 
— Treatment of compound fractures of the humerus generally, 159 



XX 



:::.".-:« .5. 



SECTION n. 

Y zz Yzz~.~.iz~:S :: viz- E:r. t? :: \i~ F zzzzzzz . 

F:i:v.::t? : .": :: . ': :zzi ~— ?'::.::: ry =:".:.:•: ::" :--ri:.-rer.: — Mr. L:r.=- 
iile's I'liz — T..T ■• A:\:t-::i: ..-. Ht::::;;;:;;:" :: M17:: — 
Fractures of the radios — Of the head of the bone — Of the shaf: — 
Of the lower portion of the hone — Dnpnytren's splint — Obi: : ■ 
fracture of the lower end of the radios — Pr, Barton 1 * node 
treatment — Fraetores of the ulna — Of the core' aid pi :<eess — Of 
the olecranon p rocess — Sir A. Cooper's plan of treatment — Other 
methods — Componnd fractures — Partial fractures, - 



171 



F:: 



secttom m. 

F_: F:i::i-rs :::xe B-:xes :: :if Wris: i:i Hi":. 

: :ie :i::i! z-zzzz-s — 0: :'.:.- rxi:.i:i:;.i'_ ;:::t5 — C 1 :" ".he 
? — C:.:::: :.:..i :':z::z:zs, - 



CHAPTER V. 



APriiATT: AV 



OflTY. 



:ViS : -• ~:-: • L : ~ r?. 



rzzzzs :: :i 
Carles B, 

::'Mt. A-~ 



sectiom I. 

F:r Fnc-rires ;:":2if 0? Fe: 



Arc 



i:.r-" t:5::::^5 — Tzz-zzzizT.' :: ~i:- 
—Br the method of Pott— Of Sir 
I if ::f : ■:.:: x Hospital — Plan 

'-. \, F, S~x.:x T^~ — ■" •""■","-",". — 



E -:■::-.— Dr. F 

H-rei:-. is = 



Lis:.:-. 



terior to this — Fiaetun 
Above the coe zj.zs — T : 

*.zr-cs :: :he ::.:r~. • 



-in ire :m7s~".it Limine::: Ex- 
lower extremity of the bone — 
lese processes — C* mpoond frac- 



155 



CONTENTS. . XXI 

SECTION II. 
For Fractures of the Patella. 

Longitudinal and transverse fractures — Plans of treatment pursued 
by Sir A. Cooper, by Desault, Gerdy, Amesbury, Lonsdale — Rup- 
ture of the tendon, and ligament of the patella — Compound frac- 
tures of the patella, - - - - - 213 

SECTION III. 
For Fractures of the Bones of the Leg. 

Of both bones, treatment by " the Junks" — By the splint of Mr. 
Neville — By the fracture-box — By the splints of Hutchinson — By 
the double inclined plane of Mr. Liston — Fracture of tibia only 
— Of the fibula only — " Pott's fracture" — Its treatment according 
to Dupuy tren — By the fracture-box — Suspension method of 
Sauter and Mayor — Compound fractures — The bran-dressing, 220 

SECTION IV. 
For Fractures of the Bones of the Foot. 

Of the os calcis — Method of Mr. Lonsdale — Of Druitt — Simple 
fractures of the bones of the foot generally — Compound frac- 
tures, - - • - - - - 232 

PART IY. 

ON THE MECHANICAL MEANS EMPLOYED IN THE TREATMENT OF DISLOCATIONS. 

General observations, _-..__ 235 

CHAPTER I. 

DISLOCATIONS OF THE BONES OF THE HEAD AND TRUNK. 
SECTION I. 

Of the Lower Jaw. 
Reduction — Retention by the bandages of Barton or Gibson, - 237 



XX 11 CONTENTS. 

SECTION n. 
Of the Bones of the Trunk, - - 2 38 

SECTION III. 

Of the Clavicle. 
Reduction — Treatment hy the crucial bandage, - - 238 

CHAPTER II. 

DISLOCATIONS OF THE B0NT1S OF THE UPPER EXTREMITY 

SECTION I. 

Of the Humerus. 

Different positions assumed — Reduction by the heel in the axilla, 
with the double roller towel — By relaxing the supra-spinatus and 
deltoid muscles — By the use of the pulleys, with the knee in the 
axilla — After treatment, ----- 240 

SECTION II. 

Of the Bones of the Elbow. 
Varieties of the accident — Restoration — Subsequent treatment, 244 

SECTION III. 

Of the lower extremity of the Forearm. 
Varieties — Reduction — Subsequent treatment, ... 245 



CONTENTS. XXlll 



SECTION IV. 

Of the Bones of the Hand. 

Of the carpal and metacarpal bones — Reduction of the phalanges — 

Reduction by various methods, - 246 



CHAPTER III. 



DISLOCATIONS OP THE BONES OF THE LOWER EXTREMITY. 



SECTION I. 

Of the Hip Joint. 

Varieties — General plan of reduction — Restoration of each variety, 
with subsequent treatment — Restoration by means of the twisted 
rope, ....... 249 



SECTION II. 

Of the Patella. 
Varieties of the accident — Restoration and after-treatment, - 255 

SECTION III. 

Of the Tibia at the knee. 

Varieties — Their mode of treatment, - 255 

SECTION IV. 
Of the head of the Fibula. 
Reduction and subsequent treatment, - 256 



XXIV CONTENTS. 

SECTION V. 

Of the Ankle. 

Varieties and treatment, - 257 

CHAPTER IV. 

COMPOUND DISLOCATIONS. 

Mode of treatment, - - - - _ _ 258 

Apparatus for the relief of partial anchylosis, ... 259 

PART V. 

ON SOME OF THE MINOR SURGICAL OPERATIONS. 

CHAPTER I. 

ON BLOODLETTING, - 261 

SECTION I. 

Operations for General Bleeding. 

Phlebotomy at the bend of the arm — Choice of the vein — Prelimi- 
nary arrangements — Position of the patient — Choice of the arm 
— Of the lancet — Mode of operating with the thumb lancet and 
with the spring lancet — Difficulties attending the operation, and 
modes of obviating them — Mode of dressing the wound — Bleed- 
ing from the hand — From the ankle — From the external jugular 
vein, - - 262 

Accidents attending phlebotomy, .... - 276 

Thrombus — Its causes — Treatment and mode of prevention, - 277 

Wound of a nerve, .._... 277 

Symptoms of the accident — treatment, ... 277 

Wound of an artery, »__... 278 
Mode of recognising the injury — treatment by compression, - 278 

Wound of a tendon — treatment, - 280 



CONTENTS. XXV 

Arteriotomy, ------ 280 

Opening- of the temporal artery — Operation of Magistel — Incision of 

one of the branches, as advised by Velpeau, - - 281 

SECTION II. 

On Topical Bleeding, - - - 282 

On Cupping — Dry-cupping — Modes of operating — Wet-cupping — 
Apparatus required — Mode of lessening the pain attending the 

application of cups, ----- 283 

On the application of leeches, - - -" - - 285 

Modes of arresting the bleeding from leech-bites, - - 288 

Mode of preserving the leech, ----- 289 

Scarification as a means of local depletion, - - - 290 

CHAPTER II. 

ON THE MODES OF EFFECTING COUNTER-IRRITATION, - 291 

SECTION I. 

Rubefacients. 

Hot water — Sand — The oils, &c. — Sinapisms — Mode of their em- 
ployment — " The spice poultice" — Preparation, - - 292 

SECTION II. 

Vesicants. 

Boiling water — Hot metal — Steam — Spanish flies — Mode of em- 
ploying the cerate — Application of the vesicant — Treatment of the 
blistered surface — Mode of relieving strangury — Cases to which 
this agent is applicable — Croton oil — Its mode of action and em- 
ployment — Croton oil plaster — The strong water of ammonia — 
Mode of employment — Granville's lotions, - 294 

SECTION III. 
Suppurative Counter-irritants. 

Mineral acids — The actual cautery, &c. — Tartar emetic — Appli- 
cation of the ointment — Dressing of the surface — Tartar emetic 

# 



XXVI CONTENTS. 

in solution and in plaster — Nitrate of silver — Application and uses 
— Caustic potassa — Mode of employment — Dressing of the sur- 
face — " The Vienna paste" — M. Canquoin's chloride of zinc paste — 
White oxide of arsenic — The actual cautery — The moxa, prepara- 
tion and employment— Issues — Their formation — Point of in- 
sertion — Setons — Composition — Mode of employment — Acupunc- 
ture — Operation — Electro-puncture — Uses — Vaccination — Col- 
lection and preservation of the vaccine virus — Modes of insert- 
ing the matter, - - - - - - 300 



CHAPTER III. 

METHODS OF ARRESTING HEMORRHAGE. 

By the action of cold — Of astringents and styptics — Matico — By 
cauterization, with the actual or potential cautery — By pressure 
with the hand, or tourniquet — By plugging the wound, or divided 
vessel — By torsion — By the application of the ligature — Mode 
of arresting epistaxis, and hemorrhage from the Rectum, - 309 



CHAPTER IV. 

ON THE DRESSING OF WOUNDS. 

Cleansing of the wound — Arrest of bleeding — Treatment of gra- 
nulating wounds — Modes of securing the apposition of the edges 
of incised wounds — By adhesive strips of lead plaster, isinglass 
plaster, and by means of the solution of gun-cotton — By the in- 
terrupted suture — By the continued suture — By the quilled suture 
— By the twisted suture — By the dry suture — By invaginated and 
other bandages, _.._._ 330 

CHAPTER V. 

ON THE INTRODUCTION OF THE CATHETER. 

Catheterism of the eustachian tube — The instrument and manner of 
introducing it — Catheter ism of the oesophagus — The stomach-tube 
and mode of using it — Catheterism of the urethra — Construction of 
the catheter, male and female, and the various plans for introduc- 



CONTENTS. XXV11 

ing it into the bladder — Mode of obviating difficulties — Mode of 
securing the catheter in the bladder — Catheterism of the large 
intestine — Catheterism of the air-passages, — - - 341 



CHAPTER VI. 

ON THE ADMINISTRATION OF INJECTIONS. 

Composition of and apparatus for injections — Injections by the rec- 
tum — Syringes and mode of employment — Preparation of the 
enema — Suppositories — Injections by the vagina — Injections by 
the urethra — Injections by the lachrymal duct - 354 

Means of diminishing pain during operations, - - 359 

Administration of opium — Of the vapours of vegetable narcotics, and 
nitrous oxide gas — Inhalation of sulphuric ether and chloroform 
vapours, ------- 359 

Appendix of formulae, ------ 365 

Lotions — Cerates — Ointments — Liniments, - 365 



ON BANDAGING, 



AND OTHER POINTS OF 



MINOR SURGERY. 



PART I 



The means employed by the surgeon in the treatment of 
the diseases to which he is ordinarily called, should first 
engage our attention : they are, in a measure, of a mechani- 
cal and chemical kind. This part of the volume will there- 
fore be devoted to the consideration : 

First. Of the instruments which it is most necessary to 
provide for daily use. 

Second. Of the materials employed for surgical dress- 
ings, and the mode of applying them, — including the use 
of water as a local application, and for bathing. 

Third. Of the means of purifying the atmosphere of the 
patient's apartment, 

3 



CHAPTER I. 

ON THE INSTRUMENTS USED IN DRESSING. 

The instruments which the daily avocations of the sur- 
geon call for, are of various kinds. For convenience-sake 
they are arranged in a " pocket-case." They may be 
multiplied according to the fancy of the surgeon ; but those 
which will be found most useful are, the dressing and dis- 
secting forceps, a pair of scissors, bistouries, scalpels, a 
thumb-lancet, an abscess lancet, a director, probes, a tena- 
culum, curved needles, a porte-caustic, a double catheter, 
ligatures. 

The uses of the dressing forceps are manifest, in the re- 
moval of soiled dressings, covered, as they very often are, 
with acrid and irritating secretions ; in the loosening and 
withdrawal of decayed bone, and other foreign matters, 
from sinuses, deep wounds, and such points as are of diffi- 
cult access to the fingers alone. 

The scissors used by the surgeon may be straight or 
curved. 

There should be two bistouries in the pocket-case : a 
sharp-pointed and a probe-pointed. The circumstances in 
which each will be most advantageously employed, will 
readily suggest themselves to the operator. 

The director and the probes should be of silver, as be- 
ing flexible, and less liable to be injured by contact with 
the various fluids with which they will meet, than if made 
of steel. The probes should be of various sizes, and one 
should be made with an eye in its flattened extremity, for 



INSTRUMENTS USED IN DRESSING. 



27 



Fig. 1. 



the purpose of being armed, if occasion require, with a 
ligature, a skein of silk, or a piece of tape. 

The porte-caustic should be of platinum, as this metal 
best resists the action of nitrate of silver, which is the 
caustic generally carried in the pocket-case. The plati- 
num cup may be fitted to a 
stem of wood, or it may be so 
made as to be received into a 
silver case ; the latter is the 
best arrangement. In addition 
to the lunar caustic, the sur- 
geon will find it convenient, 
oftentimes, to have a crystal of 
the sulphate of copper in his 
case. 

The double catheter is made 
of silver, as is the common 
male, or female, catheter. It 
consists of three pieces, as re- 
presented in the annexed draw- 
ing, (see fig. 1.) A, a straight 
tube, about five inches long, 
having at its upper extremity 
two rings firmly soldered to 
the tube at points opposite to 
each other ; while the lower 
extremity has a female screw- 
thread cut upon it, of half an 
inch in length : B, a beak, an 
inch and a half or two inches 
long, slightly curved, its lower 
extremity closed and rounded, 
while the upper end is provided 
with a male screw, corresponding with the female screw 




28 INSTRUMENTS USED EN DRESSING. 

of the staff which is intended to receive it. Just above 
the lower extremity of this beak, two oval or rounded 
fenestra? are cut, one on each side, thus throwing open 
the cavity : C, another beak, about seven inches long, 
bavins; a curve similar to that of the ordinary male cathe- 
ter, and its upper and lower extremities adjusted as 
are those of the shorter beak. By simply screwing the 
short curved piece to the staff, we have an elegant female 
catheter ; by similarly attaching the long curve, a male 
catheter. When in the pocket-case, the short beak should 
be kept screwed to the staff. 

This instrument is very well made by Mr. Warner of 
this city, Commerce Street. The tube should be thicker 
and stronger than that of the ordinary catheter, and care 
should be used that the joints be accurately fitted. 

The advantages of having so important an instrument as 
this reduced to a form so portable, need not be insisted 
upon. 

In addition to the instruments above enumerated, the 
pocket-case may be made to include a spatula, a double 
canula with its wire, a seton-needle, and a razor. These, 
however, are not so essential elements of the case, as those 
before mentioned ; generally they can be dispensed with, 
or other instruments may well be used in their stead ; and 
their presence will render the pocket-case much more 
bulky and cumbersome. 

The blades of the bistouries and scalpels may be so made 
as, when not in use, to be concealed within the handle, as 
the blades of the ordinary pocket-knife : by this arrange- 
ment, the edge of the instrument will be protected from 
injury. 



CHAPTER II. 

ON SURGICAL DRESSINGS. 

The various appliances used in surgical dressings, may 
be thus enumerated : lint, cotton, tow, compresses of vari- 
ous kinds and forms, sponge-tent, setons, adhesive and 
other plasters, poultices, lotions, cerates, ointments, lini- 
ments, bandages, sponge, and apparatus of various kinds, 
more or less complex, for special purposes. Some descrip- 
tion of each of these will be necessary. 

1. Lint is the soft fleecy substance obtained by unravel- 
ling old linen. It may be procured in the shops in the 
form of what is called " patent lint," or it may be prepared 
as required for use, by scraping, with a sharp knife, the 
surface of old linen, previously put upon the stretch. The 
linen selected for its preparation should be soft, from use 
and washing. As thus obtained, the lint is very light and 
delicate, and admirably adapted to absorb the secretions of 
parts to which it may be applied. The " patent lint" is 
sold in sheets or rolls, one of its surfaces is fleecy, the 
other is smooth : its texture is compact, certainly not 
nearly so porous as the loose lint, hence it absorbs much 
less readily and freely than the latter. Both varieties of 
lint are applied dry, or covered with cerates, or saturated 
with some kind of lotion. 

The French surgeons employ an admirable sort of lint, 
which they term " charpie." It is now very generally used 
in this city, and, indeed, throughout the country, when it 

3* 



30 SURGICAL DRESSINGS. 

can be procured. It is thus made : — linen, of a coarse or 
fine texture, according to circumstances, is cut into small 
pieces, a few inches square, and its tissue completely un- 
ravelled, thread by thread. The coarser kind of charpie 
may be made of old table-cloths ; the finer sort of a lighter 
material. Velpeau gives a decided preference to charpie 
made of old linen, as being much more absorbent, and 
much less irritating, than that made of the new fabric. 

(Charpie of an excellent quality is made in this city by 
Mrs. Jones, southwest corner of Walnut and Juniper Streets, 
and is kept for sale in many of the apothecary shops.) 

Lint, in its various forms, is used as a simple application 
to ulcerated or excoriated surfaces ; to favour an equable 
and even pressure upon any part ; to prevent adhesion be- 
tween the walls of cavities, natural or accidental ; to ab- 
sorb various secretions, and as a vehicle by which medi- 
cinal applications may be made, when and wherever re- 
quired. 

Various arbitral*}' terms have been applied to no less 
arbitrary forms, which lint, and especially charpie, may 
be made to assume, as an element of surgical dressings. 
Thus, there is the plumasseau or pledget, the roll, the 
bullet, the mesh, the tent, the tampon, the pellet, &c. 

The plumasseau is prepared by simply folding, at the 
middle, a sufficient number of the filaments of charpie, 
previously laid parallel to each other. For the sake of 
neatness, the ends of the threads may be cut off evenly, or 
inverted, and the mass thus formed moulded by the hands 
to any shape, flat, round, circular, square, or oblong, to 
adapt it to particular parts. 

The roll is a mass of charpie, rendered cylindrical by 
the hands, and firmly tied at the middle. It is chiefly used 
to arrest hemorrhage, by pressure, from a deep-seated 
vessel, or to absorb the secretions from wounds or cavities. 



SURGICAL DRESSINGS. 31 

For convenience in withdrawing the mass, the string, tied 
about the middle, may be left attached at this point, and 
projecting from the orifice. 

The term bullet is applied to a small mass of charpie 
or common lint, rolled into the form of a small ball. A 
number of these may be advantageously used for the same 
purposes as the roll just described. 

The mesh resembles the roll very much in its uses ; its 
fibres are left loosely floating, instead of being rolled to- 
gether. It is sometimes employed in the treatment of 
sinuses and fistulous canals, by being thrust to the bottom 
of such cavities, on the end of a probe, with the view of 
preventing their healing at the orifice. It may be intro- 
duced dry, or covered with some lotion or cerate, more or 
less stimulating. 

The tent of charpie is made by twisting a certain 
amount of this substance into the form of a cone. For the 
purposes for which a tent is generally required, it is very 
much inferior to the sponge tent. 

The tampon is merely a large ball of charpie, or it may 
be a number of bullets. It is used in the plugging of bleed- 
ing wounds, &c. 

The pellet consists of a ball of charpie or common lint, 
enclosed in a piece of soft linen, firmly tied. It may be 
used as a tampon. 

The good sense of the surgeon or dresser, will enable 
him to employ these different forms of lint seasonably, or 
to invent others still better. 

2. Cotton may be used with advantage in many cases. 
Its cheapness — and the almost universality of its diffusion — 
are of themselves great recommendations, in connexion 
with its softness, lightness, and the porosity of its texture. 
It is sold either as " carded cotton," or, in the form of " sheet 
cotton," in large sheets, of which both surfaces are smooth, 



32 SURGICAL DRESSINGS. 

more or less glazed, forming as it were thin pellicles be- 
tween which the true cottony mass is inclosed. As an 
application to secreting surfaces, it will be found to be less 
absorbent than lint, and probably more irritating. It is 
very much employed as a covering to extensive superficial 
burns, to protect their sensitive surface from the action of 
the air and other irritants. But when there is much sup- 
puration or other discharge, the cotton, becoming more or 
less imbued with the secretion, is heavy and heating, and 
is readily displaced by slight movements of the patient, 
becoming rolled into hard masses. Probably every dresser 
has been often much annoyed, by the difficulty which he 
has experienced in removing from a large moist sore, these 
numerous indurated pellets of cotton, which sometimes ad- 
here very tenaciously to the granulations. Its chief uses — 
and for these it is almost invaluable — are, to form a soft 
bed in which an injured part may be reposed, to prevent 
unpleasant pressure and excoriation from bandages and 
other apparatus, and to envelope parts, of which the natu- 
ral temperature has become depressed. 

3. Tow is never applied directly to a secreting or abraded 
surface ; being too harsh and irritating. It is made use of 
in enveloping other dressings in cases of profuse discharges, 
as in compound fractures, suppurating stumps, &c. 

4. The compress is employed for a variety of purposes. 
As the name imports, it was at first used to effect, or to 
facilitate, pressure upon any part; now, however, it has 
acquired a wider application, being equally adapted to the 
covering and protection of injured surfaces ; to retain other 
dressings, and to give regularity and symmetry to the form 
of a limb, or of any other part, to which a bandage is to 
be applied. 

Compresses may be made of various materials, as linen, 
muslin, w 7 oollen fabrics, lint, cotton, tow, &c. When in- 



SURGICAL DRESSINGS. 33 

tended for direct application to secreting surfaces, they 
should be of lint or soft linen, and applied dry or anointed. 
The advantages of a flannel compress are, its elasticity, its 
warmth and the readiness with which it imbibes any 
moisture of the surface. The cheapness of the different 
fabrics of cotton recommends them for many purposes ; 
for wherever economy may be properly consulted, without 
conflicting with more important considerations, the sur- 
geon, whether in hospital or in private practice, should not 
fail to be influenced by it in the choice of the material for 
his dressings. Whenever a compress is to be employed 
external to other dressings, or upon an uninjured surface, 
it may, as a general rule, be formed of cotton stuffs, as 
properly as of linen. 

For convenience, accuracy, and neatness of application, 
compresses are made of divers forms and shapes, to suit 
particular cases and indications ; Velpeau's division is a 
very simple one, into the plain, the divided, and the folded. 
The most important are, the square, the graduated, the 
perforated, and the split compresses. 

The square compress is sufficiently well described by 
its name, as are also the oblong and the triangular com- 
presses ; their size and thickness may vary at the pleasure 
of the surgeon, and with the requirements of each case. 

The graduated compresses are so contrived as that they 
shall present a gradually diminishing surface at the sum- 
mit, as their thickness increases. 

The common graduated compress may be made by 
taking a strip of any material of the required width, and 
folding it upon itself so that each successive fold shall be 
shorter than the one which preceded it. By thus regula- 
ting the length of the folds at one end only, the single gra- 
duated compress is made (fig. 2) ; by pursuing the same 
plan at both extremities, the double graduated compress. 



34 



SURGICAL DRESSINGS. 



The pyramidal compress is formed by piling successively 
on each other pieces of any material, o'f gradually and re- 
gularly diminishing size, — of square, oblong, or circular 
shape (fig. 3). 

Fig. 2. Fig. 3. 



l\>- 



uu 



M 



These varieties of the compress are useful when firm 
pressure, made generally with the aid of a bandage, or of 
the hand, is required upon some deep-seated point, as, for 
example, to arrest the circulation through a bleeding ves- 
sel. 

The perforated compress, as its name indicates, is one 
in which an aperture has been cut. The number of such 
apertures may vary indefinitely. A very elegant dressing 
to a suppurating surface consists of a compress, or a sim- 
ple piece of linen, perforated in a cribriform manner, and 
spread with cerate of some kind. The pus has in this way 
free escape, and may be absorbed by lint laid upon this 
sieve-like covering. 

The chief varieties of the split compress, are the retrac- 
tor of two and of three tails, and the Malta cross. 

The retractors are formed by making one or two longi- 
tudinal slits (as two or three tails are required) in a piece 
of muslin three or four inches wide, and two and a half 
feet long. They are used in amputations to draw up the 
soft parts, after the incision has been made, for the purpose 



SURGICAL DRESSINGS. 



35 



Fig. 4. 



of protecting them from the saw, while the bone is being 
removed as high up as the incision of the soft parts will 
allow. The retractor of two tails is employed in amputa- 
tions of the arm and thigh ; the other in the removal of 
the forearm and leg. In its application, the former is made 
to grasp the bone between its tails, which are then drawn 
upwards beneath the member, the body of the retractor 
being carried in the same direction along its superior face ; 
the soft parts are thus enclosed and shielded between the 
two. In using the retractor of three tails, the middle tail 
is thrust between the two bones of the leg, or forearm. 

To prepare the Malta cross (fig. 4), 
take a square piece of linen or patent 
lint, of the required size, and fold it 
through the middle of one of its sides ; 
double the oblong thus formed upon 
itself through the centre of one of its 
longitudinal diameters, and from the 
free angle of the smaller square thus 
produced, (the angle at which the vari- 
ous laminae composing the square are 
separable), make an incision along its oblique diameter, 
to within a short distance of the opposite angle. When 
the square is reopened, it will present the form of the 
Malta cross. It is used as a direct application to stumps, 
having been previously perforated at numerous points, and 
spread with cerate. 

The half Malta cross is made by folding an oblong piece 
of linen, or patent lint, through the middle of its longitudinal 
diameter, and continuing an incision from one of its free 
angles, along the oblique diameter, nearly to the opposite 
angle. Its uses are as those of the last described. 

5. Sponge tent is prepared by thoroughly saturating 
soft sponge with melted beeswax, and subjecting it to pres- 




36 



SURGICAL DRESSINGS. 



sure as it cools. It is employed for the purpose of dilating 
wounds, fistulous canals, &c, which it effects by imbibing 
moisture from the cavity, and thereby swelling. For use, 
a piece of the hardened mass of sponge is cut of the re- 
quisite size and form, and gently introduced into the cavity, 
where it may be easily confined by a piece of adhesive 
plaster stretched across the orifice. 

It is well to recollect that the prolonged retention of a 
sponge tent, particularly in irritable patients, frequently ex- 
cites violent pain, swelling, and heat in the part, accom- 
panied often with considerable fever. In such cases, these 
effects speedily disappear upon the removal of the tent, 
followed or not by the application of some soothing dress- 
ing, as warm water, or a poultice. 

6. Setons are made of a variety of materials : as of a 
skein of silk, a piece of linen tape, or a piece of ordinary 
soft linen, which has been unravelled along its borders. 

7. Adhesive plaster, is composed of some substance or 
substances, possessed of tenacious or adhesive properties, 
and susceptible of being spread upon linen, muslin, or some 
similar material. 

The "emplastrum resinaV , of the U. S. Pharmacopoeia, 
is the one generally employed in this country. It is sold 
in the shops already spread upon linen or muslin. (The 
adhesive plaster made by Charles Ellis, of this city, is par- 
ticularly excellent.) 

Adhesive plaster is one of the most indispensable articles 
of dressing to the surgeon. Its uses are numerous. 

Its most frequent employment is in the approximation of 
the lips of wounds. For this purpose, the plaster should 
be cut into strips, varying in width according to circum- 
stances, but, for neatness-sake, the strips intended for the 
same dressing should be of equal width. In cutting 
them, the sheet of plaster should be made tense by the 



SURGICAL DRESSINGS. 37 

hands of the surgeon and an assistant, while the former 
forces a pair of sharp scissors, without closing the blades, 
across the sheet parallel with the course of its threads ; in 
this way the strips may be cut straight and very rapidly. 

For application, the strip should be warmed, by being 
held near a fire, or, which is much better, by wrapping its 
unspread surface around a vessel containing boiling water ; 
the wound having been carefully cleansed, and the sur- 
rounding surface washed and dried, and freed from hair, 
one extremity of the strip is placed upon the skin at a suit- 
able distance from the edge of the wound, — the distance 
varying according to the degree of force which shall be 
requisite to retain the edges in contact, — the edges them- 
selves are accurately approximated by the fingers of the 
dresser, and the strip is drawn across them, and pressed 
all along its course upon the skin. 

If the wound is so long as to require the application of 
two or more strips, spaces should be left between them, to 
permit the escape of fluid. 

The length of time, during which the plaster should re- 
main, must vary in different cases. Generally, the strips 
should not be disturbed until the wound has cicatrized, or 
until its edges are somewhat firmly agglutinated, unless 
they shall have become previously loosened from acci- 
dental causes, or productive of some unpleasant effect. 

In removing the dressing, the portions of the strip on 
each side of the wound should be raised alternately, and 
fresh pieces applied as soon as possible, if the same dress- 
ing is to be continued. Where a wound is traversed by 
more than one strip, a fresh one should take the place of 
each, as it is removed, before a second is withdrawn. 
This precaution is necessary, in order that the delicate ad- 
hesions of the lips of the wound shall not be destroyed or 
weakened. 

4 



38 SURGICAL DRESSINGS.' 

Many years ago, Mr. Baynton, an English surgeon, re- 
commended the employment of adhesive plaster in the 
treatment of ulcers. The plaster which he used was com- 
posed of six drachms of resin melted with a pound of lead 
plaster. He directed that the ulcer be first carefully 
cleansed, and the surrounding surface denuded of hair; 
that adhesive strips, two inches wide and of sufficient 
length to encompass the limb, and, in addition, to extend 
four or five inches over the edges of the ulcer, be passed 
around the leg, from an inch below to two or three inches 
above the sore, and with sufficient force to approximate 
slightly its edges, — each successive strip being in contact 
with that last applied ; that compresses of soft calico be 
placed around the limb, and the whole enveloped with a 
bandage from the toes to the knee. If there should be 
much heat or pain in the limb, cold water may be applied 
over the dressing. This treatment is best adapted to 
chronic indolent ulcers, attended with swelling and indu- 
ration of the limb. As the tumefaction abates, the dress- 
ings are to be applied more tightly : they should be 
changed more or less frequently according to the greater 
or less amount of suppuration, from twice in twenty-four 
hours, to once every three or four days. According to the 
experiments of Velpeau, Boyer, Roux, and others, ulcers 
are cured more speedily by this method of treatment than 
by any other ; walking about on the limb, moderately, 
facilitates the cure. Boyer found that the average length 
of treatment by this mode, calculated from a large number 
of cases, was twenty-six days ; while, according to Du- 
chatelet, of 690 cases treated by the ordinary methods, the 
average duration of treatment was fifty-two and a half 
days. (Cutler, p. 210-11.) 

The ordinary adhesive plaster of the shops will very well 



SURGICAL DRESSINGS. 39 

answer the purpose of that employed by Baynton. Pre- 
vious to its application, the limb, from the toes to within a 
few inches of the ulcer, should be enveloped by a roller, 
which is to be continued over the whole leg after the other 
dressings have been applied. 

In the drawing, fig. 39, this method of treatment is illus- 
trated, the upper part of the ulcer being purposely left ex- 
posed. 

The same plan of treatment has been extended by Vel- 
peau, Boyer, and Roux, to all ulcers which have become 
atonic or chronic, and by the former of these distinguished 
surgeons, particularly, to burns (Velpeau, Med. Operat., 
vol. i. p. 257), and also to varicose and ganglionary tu- 
mours, &c, &c. 

M. Frieke, of Hamburgh, first called attention to the 
efficacy of compression, methodically and carefully made 
by strips of adhesive plaster, in the treatment of epididy- 
mitis. They may be thus applied : the scrotum should be 
carefully cleansed, and the hair shaved from it ; the testicle 
is then forced to the bottom of the sac, and the affected 
side of the scrotum, clasped just below the ring by the 
thumb and forefinger of the left hand, is surrounded by a 
very narrow strip of plaster, which is then carried down 
over the scrotum in such a way as to apply itself neatly 
and smoothly to the skin ; successive strips are used, 
until the part is entirely enveloped. The pressure should 
be moderate and regular. As the swelling subsides, the 
strips will of course become loose, when they may be re- 
moved and fresh ones applied as before. If there be much 
pain, the employment of the adhesive plaster may be pre- 
ceded by the application of leeches over the scrotum itself, 
or in the groin. 

Chronic indurations generally of the testicle are very 
often removed or diminished by this treatment. The 



40 



SURGICAL DRESSINGS. 




annexed drawing illustrates this applica- 
tion (fig. 5). 

It will frequently be found that, after 
the removal of adhesive strips from the 
surface of the body, a portion of the ad- 
hesive matter remains upon the skin ; 
water alone will not easily remove it, but 
gentle rubbing with a sponge moistened 
with spirit of turpentine, will readily 
cleanse the part. The black discolora- 
tion often noticed, is a matter of no con- 
sequence ; it is simply owing to the ac- 
tion of the matter of the secretions of the 
surface upon the lead plaster. 
Several objections have been urged 
against the employment of the common adhesive plaster ; 
some of them are well founded, others not so. It some- 
times, though by no means usually, irritates the skin, pro- 
ducing an erythematous inflammation, and occasionally a 
papular or a vesicular eruption ; this is particularly the 
case, when the application is made to the skin of young 
children and infants. To avoid such inconveniences, the 
" isinglass plaster" has been recommended as a substitute 
for the other. It is prepared by spreading upon oiled silk, 
or silk glazed on one side only, and on the unglazed side, 
a solution of Isinglass in Spirit (Liston). When dry, the 
silk may be laid aside until required for use^ then it is cut 
into strips of the desired width, and its adhesive surface 
softened by the application to it of a hot moist sponge ; the 
strips are to be employed as directed for the ordinary ad- 
hesive plaster. The advantages of this preparation are, its 
cleanliness, its perfectly unirritating nature, and its trans- 
parency, whereby the surgeon is enabled to see the condi- 



SURGICAL DRESSINGS. 41 

tion of the surface upon which it is applied, without remo- 
ving the strips. It is, however, less adhesive than the 
common plaster ; for, as has been well observed by Dr. 
Smith (" Minor Surgery," p. 38), the warm discharges 
from the part to which the isinglass plaster is applied, 
soften its material, as did the hot moist sponge. Therefore, 
wherever considerable tenacity of adhesion is requisite, the 
ordinary plaster is preferable. 

(The isinglass plaster is made in this city by Mr. Hus- 
band, Apothecary, Spruce Street.) 

Various other plasters are frequently employed by the 
surgeon. 

The soap plaster — " Emplast. Saponis," — spread upon 
soft sheepskin, and then cut into strips, or into pieces of 
any shape and size, will be found oftentimes to answer a 
very admirable purpose, in making pressure upon an en- 
larged joint, or an indolent tumour, &c, &c. It is very 
mild and unirritating, and preserves the integuments soft, 
and moist, and is an excellent preventive of excoriation. 

The mercurial plaster is very commonly employed as a 
resolvent of tumours, and other indurations. The bella- 
donna plaster is an excellent anodyne application. 

Plasters should be smoothly and evenly spread on coarse 
muslin, or stiff brown paper, or, which is much the best 
material, on soft sheepskin. A piece of skin, or other 
material, should be cut of a shape suitable for application 
to each particular part, and rather larger than the surface 
intended to be covered by the plaster ; a narrow strip of 
paper may be then pasted around its margin, and within 
the space thus bounded, the plaster is to be spread, after 
which the paper may be removed. In order that it may 
adapt itself smoothly, accurately, and neatly to the surface, 
it is well to make several slits from the margin of the plas- 
ter towards its centre. 

4# 



42 SURGICAL DRESSINGS. 

8. One of the most common articles of dressing, both in 
domestic and professional practice, is the poultice. When 
badly made, it is undoubtedly deserving of the abomina- 
tion, with which it is so amusingly and feelingly regarded 
by Mr. Liston ; but when properly prepared, and correctly 
used, it cannot, we think, be conveniently dispensed with 
for any other substitute whatever. 

The poultice should be always soft and moist, and these 
requirements should be kept in view, as far as possible, in 
the choice of the materials of which it is to be made. The 
substance which is to form its basis is generally in the 
form of a powder ; this should be stirred about with suffi- 
cient water to give to the mass a soft consistence, yet not 
so moist as to permit the fluid to flow from it. The water 
may be cold or hot, according to circumstances, and may 
be best incorporated with the powder by adding small por- 
tions of each alternately and successively. The semi-solid 
mass thus prepared may be spread upon a piece of muslin 
smoothly and evenly, by the aid of a wooden or iron spa- 
tula, or an ordinary table-knife ; it should be from a fourth 
to half an inch thick, and occupy just so much of the sur- 
face of the muslin as that the margin of the latter may be 
reflected upon it, all around, for the space of half an inch ; 
this latter arrangement gives to the poultice a very neat 
and elegant appearance, and facilitates very much its re- 
moval from the surface to which it may have been applied. 

Some surgeons prefer to protect the part from immediate 
contact with the poultice, by the intervention of a piece of 
fine cambric or gauze, previously laid upon the surface of 
the latter. For so doing, they urge that, otherwise, por- 
tions of the poultice remain adherent to the skin or ulcer, 
after the mass has been removed, and are displaced with 
some difficulty and occasional pain to the patient. If, 
however, the poultice has been properly prepared and ap- 



SURGICAL DRESSINGS. 43 

plied, and not too long retained, this annoyance will rarely 
occur. Moreover, by thus covering the poultice, we are 
deprived, in a great measure, of the benefit derivable from 
the direct contact of its materials with the affected part ; 
and this consideration is an important one oftentimes, as, 
for example, when the poultice is medicated ; for, as Vel- 
peau remarks, " poultices are not intended to act merely 
as compresses saturated with warm water." Yet when 
the application is intended for the eye, or the neighbour- 
hood of the nostrils or mouth, or when it contains ingre- 
dients which may be too irritating for the sound skin, it is 
very proper to use the precaution alluded to. 

Generally, the smearing of the poultice with oil, or grease 
of any kind, is unnecessary and objectionable. 

In order to retain the warmth and moisture and softness 
of the poultice as long and as completely as possible, it 
should always be covered externally with a piece of oiled 
silk, or thin India-rubber cloth; the unpleasant odour of 
the latter, however, renders the first a preferable applica- 
tion. 

This dressing should be changed at least twice daily ; 
and when the discharge is profuse, in warm seasons, when 
the poultice is very soon soured — or when the speedy pro- 
duction of suppuration, or the relief of great pain is desired, 
the applications should be renewed as often as every two 
or three hours, or even still more frequently. 

In removing it, the poultice should be gently drawn up 
by one side, and reflected upon itself gradually, until the 
whole is lifted up ; if it adhere at any point, its detachment 
will be easily effected by allowing a little warm water to 
trickle over the part ; before applying a fresh dressing, the 
surface should be carefully and gently cleansed. 

To retain the application in its place, a roller may be 
passed around it, extending a short space both above and 



44 



SURGICAL DRESSINGS. 



below it. But it often occurs that the part to which the 
poultice is applied, whether it be an irritable ulcer or other- 
wise, is too tender and painful to bear the agitation to 
which it must be subjected in the use of the roller; in 
such cases the " bandage of Scultetus" should be employed; 
thus, the entire dressing may be renewed without moving 
the suffering part. 

Dr. Hays, of this city, is in the habit of making use of a 
bandage, in similar cases, which may be considered as a 
modification of the many-tailed bandage ; its simplicity 
and perfect adaptation to this and numerous other analo- 
gous purposes, renders it worthy of description. 



Fig. 7. 



Fig. 6. 




A piece of muslin more than 
wide enough to envelope the part, 
as the leg, for instance, and rather 
longer than the poultice, or other 
application which it is intended to 
retain, is cut or torn, transversely 
from each margin, leaving a cen- 
tral space entire, of some few 
inches in breadth ; this is laid on 




SURGICAL DRESSINGS. 45 

the pillow or bed, and the leg, with the poultice applied, 
is placed upon it; then, commencing from below, the tails, 
first on one side and then on the other, are alternately and 
successively brought over, as the strips of the bandage of 
Scultetus, and the last two tied in a single or double bow- 
knot. This simple bandage will be found very useful in 
retaining blisters, cerates, or any similar application, upon 
parts too sensitive to admit of much disturbance : figs. 6, 7, 
exhibit this bandage, free, and applied. 

If the discharge is at all profuse, it should be absorbed 
as soon as possible by cotton, tow, or some similar sub- 
stance, arranged to receive it. Thus if the arm be the part 
affected, it should be laid upon a pillow (the patient being 
in bed) protected by a piece of oil-cloth, upon which some 
tow or bran has been placed; the same disposition may be 
made with the leg ; or this member may be conveniently 
put in a fracture-box filled with bran, or containing a pil- 
low protected as before. In order to preserve the bed- 
clothes from contact with the discharged matter, a semi- 
circular framework of wire or bamboo, should be thrown 
over the limb. (See fig. 8.) 

The material of which the poultice shall consist must 
vary with the indications to be fulfilled in each case. It 
may be emollient, refrigerant, astringent, stimulating, or 
anodyne. 

The emollient poultice, as its name implies, is made of 
perfectly bland and unirritating material. The materials of 
which it is usually prepared, are bread and milk, bread and 
water, and water with corn-meal, flaxseed meal, or slip- 
pery elm powder. Each surgeon, probably, has some 
fancy of his own with regard to what forms the best poul- 
tice, some preferring this, some that material. Abernethy, 
who seems profoundly to have studied the philosophy of 
poultices, gives decided preference to the bread and water, 



46 SURGICAL DRESSINGS. 

and the flaxseed meal poultices ; after detailing the mode 
in which the latter should be prepared, he exclaims, rap- 
turously, " When thus made, oh ! it is beautifully smooth ; 
it is delightfully soft : it is warm and comfortable to the 
feelings of the patient." (South's " Hints on Emergencies," 
p. 12.) 

The bread poultices, made either with milk or w 7 ater, 
become dry and stiff sooner than those prepared with flax- 
seed meal : the latter contains a considerable portion of oil, 
which imparts great softness to the mass when wet ; but it 
also gives it a not very pleasant odour, and in warm wea- 
ther, or when long in contact with an inflamed surface, it 
soon becomes rancid and irritating; upon some skins, 
moreover, it produces a vesicular eruption. Perhaps the 
poultice least liable to objection, is that made of the pow T der 
of slippery elm bark. 

The above-named poultices when applied cold may be 
termed refrigerant An application of this kind may be 
prepared by employing a solution of acetate of lead, in the 
proportion of 3ij. or 3iij. to a pint of w T ater, instead of sim- 
ple water, in mixing the poultice. In order to increase 
their cooling effect, they may be applied without covering 
them with oiled silk, or any bandage, so that evaporation 
shall be unchecked. It must be recollected, however, that 
although cold when first laid upon the part, they soon ac- 
quire the same temperature as the surface ; they require, 
therefore, frequent renewal. 

Astringent poultices may be made by incorporating any 
powder of astringent property, with some one of the mate- 
rials already mentioned. The substances most frequently 
used are powdered oak bark, galls, and alum. A very 
elegant poultice of this kind is prepared by rubbing up 
alum with the white of egg. 

Stimulating poultices are formed in the same way, by 



SURGICAL DRESSINGS. 47 

incorporating stimulating substances with some sort of 
meal, and water. With this view the scrapings of carrot, 
or horseradish, are employed. Solutions of chloride of 
lime, or of soda, of creasote, or of common soap, are often 
used ; or a poultice may be made of stewed onions. One 
of the best and most agreeable of the stimulating poultices 
is the camphor poultice, made by incorporating spirits of 
camphor with the meal or other substance used as the 
basis. It is particularly serviceable as an application to 
gangrenous parts, sloughing ulcers, &c. 

The fermenting poultice is made by incorporating yeast, 
or porter, with corn meal, and is of great advantage in 
hastening the separation of gangrenous parts. A very 
common preparation of this sort is the ordinary mustard 
poultice. These applications are employed when a decided 
irritant or stimulating effect is indicated. 

An anodyne poultice may be made by stewing bruised 
poppy-heads until they become somewhat soft and adhe- 
sive; or the dregs of opium, left after the preparation of 
laudanum, or this liquid itself, may be mixed with meal; or 
the bruised leaves of belladonna may be moistened, and 
applied. The leaves of the tobacco plant moistened, may 
be used in the same way, but their application should be 
carefully watched, lest too great prostration ensue. Hops, 
or chamomile-flowers, enclosed in a flannel bag wrung out 
of hot water, form an excellent anodyne poultice. 

Medicated poultices may be very elegantly prepared, by 
making an infusion of the substance, whatever it be, which 
has been selected as a medicament. Poppy-heads, the 
carrot, potato, horseradish, various astringent substances, 
may be simmered for an hour or two in a closed vessel 
containing water, and the liquor, after having been strained, 
incorporated with meal of some kind. (South, p. 11.) 

Mr. Liston, and some others, object altogether to the use 



48 SURGICAL DRESSINGS. 

of poultices, proposing to substitute water, medicated or 
simple, cold or warm. For this purpose, some one of the 
infusions above mentioned will answer very well. They 
should be applied by means of linen, lint, or flannel, several 
times folded, and saturated with them, thus constituting 
fomentations ; they should be kept constantly upon the 
part. To be of real benefit, their employment demands 
assiduous and unintermitting care from the attendants, 
much more, indeed, than can be generally expected or ob- 
tained, particularly in hospitals; this constitutes a serious 
objection to their being generally used as substitutes for 
poultices. Neither do they supply the same body of heat 
as the latter, when heat is required. They are, however, 
more cleanly than the poultice, and this seems to be their 
chief advantage — an important one truly. Where a cold 
application of this sort is desired to reduce the tempera- 
ture of a part, the most effectual is pounded ice, with which 
a bladder, or a bag of India-rubber cloth, may be partially 
filled : the temperature of the application will remain as 
low as 32° F., so long as any particle of ice remains un- 
melted, after which the water in the sac will gradually ac- 
quire the temperature of the part to which it is applied ; 
hence the bag must be examined from time to time, and 
the ice renewed when necessary. Sacs, intended expressly 
to hold water, are made of thin India-rubber cloth ; one of 
these may be partially filled with water containing various 
saline substances which, during their solution, abstract its 
heat ; this forms a very good substitute for the bladder of 
ice, when ice cannot be obtained. One ounce of nitre, one 
ounce of sal ammoniac (chloride of ammonium), and half 
pint of water, may be thus employed. (Thomson, " Ma- 
nagement of the Sick Room," p. 277.) 

These applications, whether used in the form of poultice 
or of fomentation, fulfil a variety of indications. When 



SURGICAL DRESSINGS. 49 

employed warm, they relieve spasmodic pain, or sometimes 
continued pain ; produce or promote suppuration ; allay irri- 
tation frequently and sometimes inflammation; diminish 
cedematous enlargements, by promoting local perspiration, 
or transpiration; induce resolution of acute or chronic in- 
i flammations and indurations, &c, &c. When cold, they 
are more directly sedative and are generally used to subdue 
inflammation, or to overcome muscular action, or the tonic 
rigidity of tissues, as in the reduction of hernia. It must, 
however, be borne in mind, that the effects of these appli- 
cations vary much in different individuals ; thus in some, 
a warm poultice or fomentation, will resolve a phlegmon 
which presents, as nearly as can be judged, the same con- 
dition as one which, in other individuals, is most relieved 
by cold. The feelings of the particular patient should be 
consulted, to enable the surgeon to determine when one 
mode of treatment should be substituted for, or even be 
used instead of, the other. 

In enumerating the circumstances to which these dress- 
ings are particularly applicable, it is hardly necessary to 
remark that, the substances with which they may be medi- 
cated will modify accordingly their general action. 

9. Lotions are composed of water variously medicated. 
They are usually applied upon some soft porous material, 
as lint or folded linen ; they may be used tepid or cold ; 
in the choice of temperature, the feelings of the patient may 
be very properly appealed to by the surgeon. If a refrige- 
rant effect is desired from the wash, it should be applied 
upon a single fold of lint, or linen, and left exposed, or but 
slightly protected, so that evaporation may not be inter- 
fered with ; where such an action is not called for, several 
folds of the porous substance should be laid upon the part 
and covered by a piece of thin oiled-silk — the whole to be 



50 SURGICAL DRESSINGS'. 

retained in the manner alluded to with regard to the poul- 
tice. 

As a general rule, lotions should be employed preferably 
to cerates, as being more cleanly and not liable to become 
irritating from high temperature of the part, or season of 
the year. 

Formulas for several lotions will be found at the end of 
the volume, w 7 ith the uses of each. 

10. " Cerates are unctuous substances, consisting of oil 
or lard perfectly fresh and sweet, united with wax, sper- 
maceti, or resin, to w'hich various medicaments are fre- 
quently added. Their consistence, which is intermediate 
between that of ointments and of plasters, is such that they 
may be spread at ordinary temperatures upon linen or 
leather, by means of a spatula, and do not melt or run 
when applied to the skin." (U. S. Dispensat.) They are 
used as applications to abraded or ulcerated surfaces, and 
their composition is varied for adaptation to each case. 

11. "Ointments are fatty substances, of the consistence 
of butter, such that they may be readily applied to the skin 
by inunction." (U. S. Disp.) They are simple, or composed 
of various medicaments. The ointments, as well as the 
cerates, are easily affected by a high temperature, becom- 
ing rancid and unfit for use. They are usually applied 
upon the sound skin. 

A number of ointments and cerates, such as have been 
found useful, are given at the end of the book, with their 
particular applications. 

12. Liniments are intended for application to the unbro- 
ken surface, by friction with the hand, or soft flannel. Oil 
should constitute the basis of the liniment, and with it may 
be conjoined a variety of modifying ingredients, so that 
it may be rendered soothing, or irritating, as required. 



SURGICAL DRESSINGS. 51 

The reader will find formulae for the preparation of many 
very serviceable liniments, at the latter end of the volume. 

13. The Sponge, though it is not chiefly used as an ar- 
ticle of dressing in surgery, is of such essential importance 
to the surgeon, that a few words concerning it will be 
proper. 

The common sponge, as found in the shops, is too full of 
gritty particles to be fit for surgical purposes. It may be 
sufficiently well prepared for ordinary uses, such as the 
cleansing of uninjured surfaces, by maceration in boiling 
water, and subsequent beating, until the sabulous or calca- 
reous particles are generally removed. But for nice pur- 
poses, as the washing of inflamed or ulcerated surfaces, 
still farther preparation is requisite; after having been 
treated as above, it should be macerated in water acidu- 
lated with about one-thirtieth of its bulk of chlorohydric 
acid ; dried and beaten again, and then bleached by expo- 
sure, when moist, to the vapour of chlorine, or some other 
decolorizing agent. It is now soft and clean. 

Bandages and the variety of apparatus employed in the 
treatment of surgical diseases and injuries, will be consi- 
dered hereafter. 



CHAPTER III. 

GENERAL RULES POR DRESSING. 

If a surgeon is called upon to attend to an injury just 
occurred, he should take a rapid yet careful observation of 
the patient, in order to ascertain the condition of his 
strength and mental functions, and to discover if there be 
any circumstances calling for prompt attention previous to 
the systematic application of a dressing. Thus, if there be 
much prostration present from any cause, fresh air and 
cold water should be freely employed to revive the patient ; 
or a little wine and water, with or without laudanum, 
should be administered ; and all obstacles to free respira- 
tion, such as a cravat, a tight vest, pressure around the 
abdomen from tight pantaloons, should be at once removed. 
If there be an external wound, it should be immediately 
examined, and prompt measures taken to arrest hemor- 
rhage, if any exist. 

As soon as these preliminaries have been attended to, 
the surgeon may proceed to the regular application of the 
dressing, as in an ordinary case where no such emergen- 
cies present themselves. 

Having first arranged such articles of dressing as are 
likely to be needed in the case under consideration, and 
conveniently disposed of the necessary instruments, (all 
useless display being avoided, as being not only uncalled 
for, but positively annoying to the patient,) — and having 
at command sponges and towels, and one or two basins of 



GENERAL RULES FOR DRESSING. 53 

warm water, the surgeon should expose the diseased or in- 
jured part. In doing this, great care and the utmost gen- 
tleness should be observed; if the patient be dressed, and 
the affected part, as, for example, the arm or leg, be very- 
sensitive and painful, the clothes should be removed by 
ripping them along a seam, rather than be drawn off in the 
usual manner ; and any application which may have al- 
ready been made must be withdrawn with the same care, 
so as not to inflict any unnecessary suffering. 

The affected part and the surrounding surface should 
now be cleansed as perfectly as can be effected, without 
too much pain, by means of a sponge and castile-soap and 
water ; in addition, if there be a wound, or if it be deemed 
advisable to apply adhesive plaster, the surface should be 
denuded of hair, either by using a razor, or, which will 
answer equally well, a sharp scalpel. 

If there be hemorrhage to any notable amount, it should 
be arrested at once, by means of ligature or the applica- 
tion of cold, or some styptic ; or if it be very slight, a mo- 
mentary exposure to the air may control it ; or, finally, 
the surgeon may trust for its arrest to the pressure of the 
dressing which he is about to apply. 

In. the choice of the latter, the surgeon will, of course, 
consider the indication to be fulfilled in each particular 
case as of paramount importance; but it should also be 
borne in mind that, lightness, freedom from any undue 
heating qualities, and cleanliness, are also essential to the 
perfection of a dressing. The retaining bandage should 
be such as may be applied and removed with as little 
difficulty and annoyance to the patient as is consistent with 
its special object, and all unnecessary pressure and enve- 
lopement are to be deprecated. 

After the dressing has thus been completed, the patient, or 
the particular part involved, must be placed in such a posi- 



54 



GENERAL RULES FOR DRESSING. 



Fig. 8. 




tion as will most conduce to his comfort and security. 
Generally, a dependent position is to be avoided ; to pre- 
vent it, pillows may be placed beneath the limb, if the leg 
be involved, or, if it be the arm, a sling may be used to 
support it. 

The surface may be protected, when necessary, from 

the pressure of the bedclothes, 
by placing over it an arch made 
of two semi-circles of hoop 
crossed upon each other, or of 
wires, or bamboo, fixed in a 
frame (fig. 8). 

The dressing should be dis- 
turbed as little and as seldom as is consistent with the 
successful treatment of the case ; all unnecessary renewals 
should be avoided. Generally, a dressing should not be 
renewed, or removed, so long as the first remains in place, 
is clean, free from unpleasant smell, and is comfortably 
borne, and so long as no new and untoward symptom has 
occurred. 

All soiled dressings of every kind, the sponges, basins, 
and, in short, every thing which mars the cleanly appear- 
ance of the sick-room, or vitiates its atmosphere, should be 
removed as quickly as possible, and the bedding and cloth- 
ing of the patient be kept clean and well arranged. 



CHAPTER IV. 



ON THE USE OF WATER. 



The various modes in which water is made use of as a 
medicinal agent, by the surgeon in his daily duties, consti- 
tute a very important subject for study ; and one to which 
a few pages may profitably be devoted in a treatise on 
Minor Surgery. A brief consideration, therefore, will be 
here entered into of Irrigation ; the Douche ; the Water 
and the Vapour Baths, and finally the subject of Fumigations 
will be noticed. The best modes of insuring purity of 
the atmosphere of a sick-room, or of a hospital ward, 
will also be briefly alluded to. 



SECTION I. 

IRRIGATION. 

The surgeon has a very admirable substitute for the 
refrigerant poultice in Irrigation, whereby the part may be 
kept constantly bathed in cold water of an uniform tem- 
perature. The water may be simple, or medicated by any 
of the substances before enumerated, or others similar. 
The same plan might be used to insure a hot or warm 
fomentation, if the fluid could be maintained at one and the 
same temperature, but this would be attended with so much 
difficulty, that it would scarcely be prudent to attempt it; 
since the alternate chilling and heating, to which the part 



56 IRRIGATION. 

would be exposed, from successive changes in the thermo- 
metrical condition of the water, would be productive of 
serious inconveniences and dangers. 

The simplest method of effecting irrigation is, to cover 
the part with folds of soft linen, or lint, previously moistened, 
and to conduct a constant current of water to it through 
strips of linen, or cotton wick, from a reservoir, as, for 
example, a basin placed at some convenient point. In 
order that the clothes of the patient, or his bedding, be not 
wetted, the part, — as a limb, — should be laid upon a pillow 
protected by a piece of oil-cloth so arranged as to form a 
sort of gutter, or funnel, along which the water may pass 
and fall into another reservoir placed beneath it. M. Vel- 
peau employs an apparatus, to fulfil the same purpose, 
which possesses this advantage, viz., that by it the amount 
of water and the force of the stream can be accurately 
regulated at pleasure, by turning a stop-cock. The annexed 
figure, (fig. 9,) taken from M. Velpeau's work, (Med. 
Operat. i. 265,) sufficiently explains the apparatus which 
he uses. 

The very great benefits derivable from the free and con- 
stant use of cold water in various surgical as well as 
medical diseases, have been known for ages ; from time to 
time, however, it has been neglected, and again invoked : 
it is now, once more, resorted to, in the manner just de- 
scribed. It is particularly applicable to the early treat- 
ment of severe contused and lacerated wounds ; sprains ; 
simple contusions ; dislocations, accompanied by much pain 
after reduction, and many other painful injuries and diseases 
of the joints ; phlegmonous inflammation ; some varieties 
of painful ulcers, &c, &c. (MM. Velpeau, Berard, Mal- 
gaigne, South's Ed. Chelius, &c, &c.) The feelings of the 
patient should be consulted, in determining the propriety 
of continuing or relinquishing this plan of treatment. It 



THE DOUCHE. 
Fig. 9. 



57 




should be discontinued, or at least suspended, if it increase 
the pain which it was intended to relieve, or induce sensa- 
tions of chilliness and discomfort. 



SECTION II. 



THE DOUCHE. 



Another and a very beneficial mode in which water, 
either warm or cold, may be applied to the surface of the 



58 



THE DOUCHE. 



body is, by the douche, which consists of a column of 
water varying in volume, made to fall upon the body from 
a greater or less elevation. Two series of phenomena 
attend the action of the douche : the immediate effect, or 
the shock, and that- which follows it, or the reaction. 
The intensity of these vary according to the temperature 
of the water, its volume, and the height from which it falls ; 
so that by regulating these circumstances, the peculiar 
effect to be derived from the douche, in each case, may be 
obtained. The primary, or direct result of the cold douche 
is sedative ; but, in ordinary cases, the nervous system 
more than recovers from its temporary depression, and an 
excitement ensues. This depression may be prolonged, 
and the period of excitement postponed, by gradually in- 
creasing the mass of water which falls upon the surface, 
or the force with which it descends, or the height of the 
column, or finally, by gradually lowering its temperature ; 
and by combining all these modifications, a still greater 
effect will ensue. These circumstances should be attended 
to, therefore, where a sedative influence is required. So 
soon as a certain amount of depression occurs, the action 
of the douche may be suspended, and again resumed when 
reaction commences, as indicated by the return of the pre- 
vious temperature, colour, and fulness of the part. This 
alternate action and suspension of the agent may be con- 
tinued so long as may be indicated. After the douche, the 
surface should be gently dried by the application of a soft 
towel, so as not to excite a glow. After successive and 
repeated employment of the remedy, as above recommend- 
ed, it will generally be found that reaction does not occur, 
or that it is very moderate and within bounds. 

The warm douche is productive of less depression, and 
the reaction is proportionally less in degree, than when the 
cold is resorted to. Generally, the warmer the water, 



THE DOUCHE. 59 

other circumstances being equal, the less the effects both 
primary and secondary. 

To constitute the cold douche, the temperature of the 
water should be about 40° F., rarely lower ; that of the 
warm douche may very well be borne as high as 180° F. 
(Thomson, op. cit. 289.) The duration of their employment 
must vary very much ; in this respect the condition of each 
patient at the time must be the criterion. 

The water used for the douche is rarely medicated, ex- 
cepting by the addition of salt, or of seawater. 

The douche is especially applicable to cases in which it 
is desirable to invigorate the vital functions, generally, or 
to increase the tone of particular parts or organs. 

In cases of considerable general debility, the system may 
not be able to react sufficiently if the cold douche is em- 
ployed at first ; here it is best to use the warm water, and 
gradually, on successive occasions, to lower the tempera- 
ture of the douche, as the individual may have become 
stronger. When carefully employed in this way, it is one of 
the best general tonic remedies which can be made use of. 

In local paralysis its good effects are very manifest; as, 
for instance, when directed upon the lower part of the 
spine, in cases of paralysis, partial or otherwise, of the 
sphincter muscle of the anus, or neck of the bladder ; in a 
similar condition of some of the voluntary muscles, as of 
the deltoid, resulting from an injury to the muscle itself, 
the douche should be directed upon the particular part. 
When the loss of power is more general, the effect of lesion 
of one of the central organs of the nervous system, it is 
advisable not to employ this remedy until all the active 
symptoms of such lesion shall have been removed ; such 
cases demand great watchfulness on the part of the sur- 
geon. 

The simplest mode of applying the douche is to pour the 



GO 



THE DOUCHE. 



water from the nose of a teapot, or pitcher, from some 
convenient height ; if a large stream is desired, a basin or 
a bucket can be employed. The shower-bath is a common 
name for a variety of the douche. It is made in numerous 
ways. A very simple form, and one which is very con- 
venient for surgical purposes, particularly in young patients, 
" consists of a hollow vessel made of tin, with a perforated 
bottom. The body of the vessel is of a bell-shape, with a 
hollow tube rising from the top,(Z>) and terminating in a 
broad perforated rim.(c) When the bath is to be used, it 
must be sunk in a bucket of water, until it is completely 
submerged ; the air is thus driven out of the bath, which is 
filled with water. The thumb of an attendant is then to be 
placed upon the orifice in the centre of the rim,(c) and the 
bath raised from the bucket of water. The pressure of the 

air upon the holes in the bot- 



Fig. 10. 







torn retains the water in the 
bath, and on raising the 
thumb from the upper ori- 
fice, the water is rapidly 
discharged." (Fig. 10.) Por- 
table shower-baths, holding 
from a quart to a gallon or 
more of water, are now 
made so that the patient 
mav hold the vessel himself 
above his head, and dis- 
charge the water by raising 
a valve with his finger. The 
shower bath mav act on the 



whole surface, or upon a single part which is alone ex- 
posed. After its use, the body, or the parts which have 
been wet, should be thoroughly dried by friction with a 
towel, and the person covered as soon as possible. The 



BATHING. 6 1 

best time for making use of the shower bath, or the douche, 
if other circumstances will permit, is probably soon after 
rising in the morning. 



SECTION III. 

BATHING. 

Bathing forms a very important item in the treatment of 
many surgical diseases, so that a brief consideration of it 
will not be out of place here. 

Baths are of water, simple or medicated, and of vapour, 
— of water, or of some medicinal substance ; or, again, it 
may be a simple air bath; the latter is not much resorted 
to as a remedial agent. 

The water baths are of most frequent use. For conve- 
nience-sake, they may be classed as the cold (temp. 33° to 
60° F.) ; the cool (60° to 75°) ; the temperate (75° to 85°) ; 
the warm (92° to 98°) ; and the hot (98° to 112°). (Forbes, 
art. " Bathing," in Cyclop. Pract. Med.) The thermometer, 
though answering very well as a general index of the tem- 
perature of the bath, is really a very arbitrary guide in 
preparing baths for particular individuals; since a degree 
of temperature which one person may consider " warm," 
or " temperate," may to another be disagreeably cold ; the 
feelings of the patient, guided by the judgment of the atten- 
dant, constitute a much more rational and a safer guide. 

As in the case of the douche, two series of effects are 
manifest when one takes a bath : the primary and the 
secondary. These vary in degree, with the temperature 
of the water. The greater the difference between the tem- 
perature of the bath and that of the body, the more marked 
will be the immediate effects, or the shock, and these will 
be depressing, or stimulating, as the temperature of the 

6 



62 BATHING. 

water is below or above that of the surface, and propor- 
tionally so. A cool, and still more a cold, bath produces 
directly a sedative or depressing effect ; but in the course 
of a few minutes, unless the patient be very feeble indeed, 
the system recovers from this, and an excitement, propor- 
tioned to the previous depression, takes its place. This 
condition continues a longer or shorter time, and a second 
stage of depression ensues, from which reaction does not 
occur, so long as the individual is exposed to the same 
temperature. After the patient is removed from the bath 
and properly attended to, the excitement continues for a 
time, and then gradually the system reacquires its former 
standard, or retains permanently a moderate elevation. 

A hot bath produces immediately an excitement of the 
system, as indicated by fulness of the superficial vessels, 
flushing of the face, increased force and frequency of the 
heart's action, throbbing of the vessels of the head and 
neck ; the latter phenomena are sometimes so strongly 
manifest, as to require the employment of cold applications 
to the head, and even the use of the lancet. Soon, how- 
ever, either with or without the aids just mentioned, per- 
spiration breaks out very freely upon the face, the excite- 
ment of the heart subsides, and the patient becomes more 
and more relaxed, and not unfrequently faints ; this condi- 
tion of relaxation continues for a considerable time after 
the bathing has ceased. 

The warm bath generally produces a soothing, tran- 
quillizing influence, allays restlessness, assuages pain, and 
often induces delightful sleep. The excitement which it 
causes is very moderate, and if used permanently, it may 
be considered an excellent tonic, as is the cool or cold bath, 
under proper regulations. 

Bathing is therefore applicable to a variety of surgical 
diseases. As a calmative agent, it is employed in numerous 



BATHING. 



63 



subacute inflammations, in many diseases of the skin, 
&c, &c. As a tonic, it is applicable to cases of general 
or local debility ; as a stimulant, to the same sorts of com- 
plaints ; as a depressing remedy, it is often made use of to 
overcome violent pain, spasmodic muscular contraction, 
as in the reduction of dislocations, to allay spasm of the 
neck of the bladder, to aid in the return of a hernial protru- 
sion,, and the like. 

In giving a bath, the water should be preserved, as far 
as possible, at the same temperature throughout its use. 
When the bathing is completed, the individual should be 
carefully rubbed dry with towels, and protected from ex- 
posure to a current of air. 

Fig. 11. 




Common sense will suggest at the time some apparatus 
suitable for the administration of this remedy ; if possible, 
it should be large enough to contain the entire person, but 
in the absence of such a convenience, a common water- 
cask might be employed, or a washing-tub ; — care being 
observed, if the bath be warm, to protect by a blanket 
such portion of the surface as may be uncovered by the 
water. Dr. Thomson (op. cit., p. 296) has contrived a 
very convenient apparatus for bathing ; he thus describes 
it: — "It consists of a hammock (a) of Macintosh's cloth, 
which is extended upon two long poles (b b), passed through 
a broad seam on each side of the hammock, and kept 



64 



BATHING. 



asunder by the cross pieces (c c), which are attached to 
the poles by the thumbscrews (d d d). At one end of the 
hammock is an air pillow, which can be readily blown up; 
and below it, is a flexible tube (/), made of the same ma- 
terial as the hammock, by which any water it may contain 
can be readily drawn off. When the poles are fixed, as in 
the above figure, and the open end of the flexible tube is 
twisted around one of the thumbscrews, the bath is ready 
to receive the water. It may be supported upon two chairs, 
or upon folding tressels (e e). The advantage of this bath 
is, that it requires a very small quantity of water compared 
to that demanded for other baths ; that it requires no sheet 
for the bather to rest upon ; and, when the bathing is com- 
pleted, the poles and the folding tressels can be placed 
aside in a small closet, or in the corner of a dressing-room, 
and the hammock, when dried, put into a drawer." This 
apparatus will be found very convenient on board ship, or 
in camp, where convenience in transportation and eco- 
nomy of space must be consulted. (Fig. 11.) 

Partial baths are very often used, and are of great ser- 
vice in many cases. Thus the pediluvium, or foot-bath, 
may be the means of effecting powerful and efficient deri- 
vation from the head, and of inducing a considerable de- 
gree of relaxation of the whole frame. An ordinary 
bucket may be partially filled with water of as high a 
temperature as the patient can bear, rendered more pow- 
erful, if desired, by the addition of mustard flour or cayenne 
pepper, or some liquid stimulant ; the patient may sit up in 
a chair, while the feet are in the water, or he may remain 
in bed, with his limbs projecting over its edge into the 
bucket which is supported upon a chair conveniently 
placed. He should be well wrapped up, during the pro- 
cess ; from time to time, portions of water should be with- 
drawn from the bucket, and hot water added. The bath 
may be continued for fifteen or twenty minutes, or longer. 




BATHING. G5 

The hip-bath furnishes a very con- 
venient and powerful means of acting s ' 
upon the lower part of the spinal mar- J 
row and the pelvic organs. It may (t 
be very well taken in a vessel, of which 
the annexed drawing illustrates the 
form ; it has the important advantage 
of well supporting the back, while the 
patient is in the sitting posture. (Fig. 12.) 

Baths are variously medicated to suit particular indica- 
tions ; several of such modifications will be given at the 
end of the volume. 

The vapour bath may be made to answer many of the 
indications fulfilled by the water bath ; its general effects 
are very similar. The intensity of its action varies much, 
according as it is allowed to act upon the surface merely, 
or as it is inhaled also. Dr. Forbes, (art. " Bathing," op. 
cit.) gives the following comparative statement, by which 
it is supposed that the vapour bath produces effects equal to 

The tepid bath, at 85°— 92°, its own temp, being 90°— 106°, 90°— 100° 
"warm " 92°— 98°, " " 106°— 120°, 100°— 110° 

"hot " 98°— 106°, " " 120°— 160°, 110°— 130° 

Not breathed. Breathed. 

Their administration is very simple, and is attended with 
less inconvenience, oftentimes, than the use of the water 
bath. The readiest mode of giving a vapour bath is to 
seat the patient upon a chair, and at his feet place the 
vessel of water sufficiently heated ; surround the whole, — 
patient, chair, and water, — with a blanket, which may 
envelope the head, if it be considered advisable that the 
vapor be inhaled, or simply enclosing the neck, if other- 
wise ; to keep the water at a proper temperature, a heated 
brick may be immersed in it, or the vessel placed upon it, 

6* 



66 ON FUMIGATIONS. 

from time to time, as required by the lowering temperature 
of the fluid. If the patient remain in bed, a flexible tube 
can be easily introduced beneath the bedclothes, commu- 
nicating with the interior of a vessel, as an ordinary tea- 
kettle, in which vapour is being generated : or a plate con- 
taining the fluid and a hot brick may be placed in the bed, 
and an arched framework thrown over it to protect the 
bedclothes. 



SECTION IV. 

ON FUMIGATIONS. 

When solid substances are vaporized, and thus made to 
act upon the surface, as medicinal agents, the process is 
called Fumigation, and is effected by placing the substance 
to be used in contact with a body heated at a sufficient 
temperature, and so arranging the position of the patient 
as that the fumes may come in contact with his surface. 
The arrangements recommended above in the application 
of the vapour bath may be employed likewise in fumigating; 
the same, or even greater, care being observed to protect- 
ing the air-passages, if the fumes are irritating, or not in- 
tended to be inhaled : again, a large box, or a hogshead, 
may answer very well, being so contrived as that the head 
may be guarded against the vapour. 

The articles most frequently employed in fumigating the 
surface, or a particular part of it, — are sulphur, nitre, 
cinnabar, arsenic, benzoic acid, chlorine gas, nitrous 
acid, &c, &c. 

Vapours, whether by the vapour bath, or by fumigation, 
are chiefly employed in affections of the skin, some forms 
of chronic rheumatism, periostitis, and the like. 



DISINFECTING AGENTS. 67 



SECTION V. 



ON DISINFECTING AGENTS. 



A pure atmosphere is one of the most important re- 
quisites in the treatment of disease, and it is one which, in 
surgical practice particularly, is difficult of acquisition, 
oftentimes. It becomes necessary, therefore, that the sur- 
geon should devote some attention to this matter. 

The method which suggests itself most naturally to the 
attendant is, to effect as perfect ventilation as circum- 
stances will permit. For this purpose, some method should 
be adopted whereby the air in the patient's apartment shall 
be frequently renewed by the introduction of fresh air from 
without, displacing that within the room. When the tem- 
perature is such as to admit of keeping a fire in the cham- 
ber, the vitiated atmosphere will ascend freely through the 
chimney, thus allowing pure air to take its place ; but in 
warm weather this source of purification is cut off, and 
the surgeon is obliged to rely chiefly upon the window 
and doors, as affording avenues through which an inter- 
change may be ^effected of the air within and without. 
This mode of purification may be much aided by the use 
of various disinfecting agents, which neutralize, more or 
less, the exhalations and effluvia within the sick-room. Of 
these, the various substances which contain chlorine are 
most in use. They probably produce their effect by the 
liberation of chlorine gas, which combines with the offend- 
ing gases. The chlorides of calcium and of sodium are 
the compounds generally employed as disinfectants ; they 
are used in a solid state, placed in different parts of the 
room, in some suitable dish, and kept moistened with 



68 DISINFECTING AGENTS. 

water, or with dilute sulphuric acid which is still better ; 
or they may be rendered liquid for application to the sur- 
face of the body and to the bedclothes of the patient. 
The liquid chloride of calcium may be prepared thus : — 
Introduce into a common glass retort fourteen parts of 
black oxide of manganese, six parts of chloride of sodium, 
the same proportion of sulphuric acid, and twelve parts of 
water. The chlorine gas w T ill be evolved without the aid 
of heat applied, and should be transmitted through a tube 
attached to the neck of the retort to the bottom of a vessel 
filled with a saturated solution of lime, until the evolution 
ceases. The water thus impregnated should be diluted 
with about forty parts of fresh water, for ordinary use. 

The liquid chloride of sodium is prepared in the same 
manner : a solution of one part of sub-carbonate of 
soda, in twenty parts of water, being substituted for the 
lime-water. The solution should be diluted with about 
thirty parts of water. These liquids are sprinkled upon 
the patient's clothes and bedding, and a portion may be 
added to the water used in washing any diseased part: for 
this latter purpose, the solution of the chloride of sodium 
is generally preferred, (Cyclop. Pract. Med.) 

Labarraque's solutions of these chlorides are now sold 
very generally throughout the country. . 

A solution of the chloride of zinc is also employed as a 
corrector of the atmosphere. 

Chlorine gas may be very easily liberated from common 
salt, by pouring concentrated sulphuric acid upon it, in the 
proportion of one part of the acid to three parts of the 
salt. 

An objection to the use of the chlorides arises from the 
smell of the preparations themselves being disagreeable to 
many persons. 

Fumigations by nitrous acid vapour have been resorted 
to, and with much success. The vapour is obtained by 



DISINFECTING AGENTS. 69 

the action of sulphuric acid on nitrate of potassa, in equal 
proportions, without the aid of heat ; care is necessary lest 
the fumes be disengaged too rapidly and too abundantly, 
and thus prove a source of irritation to the respiratory 
muscles. 

The common quicklime possesses the power of absorbing 
many of the gases on which the noisome atmosphere of the 
sick-room depends. It is placed in plates, or other dishes, 
and set in various parts of the chamber. 

M. Le Doyen has recently recommended a disinfecting 
agent which seems to possess many advantages over the 
others, and a very important excellence of this preparation 
is, that it has no odour itself. It consists of a solution of 
the nitrate of lead, and can be prepared by dissolving 
litharge in one part of nitric acid, mixed with about ten 
parts of water. It is used in the same way as the liquid 
chlorides. 

To insure any degree of purity of atmosphere, it is abso- 
lutely essential that the patient's apartment be kept clean, 
and that all useless clothing and furniture, which may at- 
tract offending gases, be removed. The dressings which 
have been changed, the water with which diseased parts 
have been cleansed, all vessels containing discharges from 
the patient, should be taken out of the room as soon as 
possible. Frequent whitewashing of the walls and ceiling 
of the chamber will conduce very much to the preservation 
of a pure atmosphere, probably on account of the absorbing 
property of the lime over the effluvia. 

The most efficacious method for disinfecting substances, 
such as clothing, which retain infectious agents, is to ex- 
pose them to an elevated temperature, as, for example, a 
temperature of 200° or more, of Fahrenheit's scale ; the heat 
may be employed dry, or in the form of steam. The ac- 
tion of heat is effectual in a very much shorter time than 
an ordinary current of air. 



PART II. 

OX BANDAGES AND THEIR APPLICATION. 

CHAPTER I. 

Bandages are employed in surgery to retain dressings 
upon the surface of the body, or other applications ; and 
also as a means of restoring and confining to their natural 
situation parts which may have become displaced. 

The materials used for bandages are generally muslin, 
linen, flannel, or calico: sometimes gum-elastic cloth may 
be employed. Of these materials that which is most fre- 
quently selected is muslin, either bleached or unbleached ; 
it is cheap, and everywhere to be found. Flannel is, in 
some circumstances, preferable to muslin, in consequence 
of its greater warmth and elasticity. 

Bandages are simple, as when formed from the roller ; 
or compound, when prepared from one or more pieces 
adapted by size and conformation to particular objects. 

We shall first describe the different bandages commonly 
employed, and then treat of their several uses, as applicable 
to the different regions of the body. 



THE ROLLER, OR SIMPLE BANDAGE. 



71 



SECTION I. 

THE ROLLER, OR SIMPLE BANDAGE. 

There are but very few of the ends ordinarily to be at- 
tained by bandaging, which may not be gained by a skilful 
dresser with the simple roller. 

It is prepared from any of the materials above-mentioned, 
but for general purposes muslin is selected. It should be 
torn or cut into strips, varying in length and width, ac- 
cording to the part to which it is to be applied, and rolled 
into the form of a solid cylinder : this latter object may be 
effected by the hands alone, or by making use of a very 
simple machine contrived for the purpose. If rolled by the 
hands, the strip should be folded at one extremity several 
times, until it shall have acquired a certain degree of soli- 
dity ; then the ends of this axis are held, and its mass made 
to revolve, between the thumb and forefinger of the right 
hand, while the free portion of the strip is pressed by the 
thumb and forefinger of the left hand, and allowed to pass 
from between them, smoothly, and with some degree of 
tension, as the cylinder is gradually forming. 



Fig. 13. 




72 THE ROLLER, OR SIMPLEBANDAGE. 

Figure 13 presents a view of a machine for rolling the 
simple bandage: it sufficiently explains itself. (Fig. 13.) 

If but a single cylinder is formed, the roller is said to be 
" single-headed ;" if there be a cylinder rolled at each ex- 
tremity of the strip, it is called " double-headed," and the 
unrolled portion between the two cylinders is termed the 
" body" of the roller. 

In applying this bandage, the external surface of the 
free extremity of the roller is laid upon the part, and re- 
tained there by the fingers of the left hand, until fixed by a 
few turns of the roller, the cylinder being held in the palm 
of the right hand, by the thumb and fingers ; care is neces- 
sary that the bandage be laid smoothly and evenly upon 
the surface, and that a uniform degree of pressure be ex- 
erted by each successive turn. After the rolling is com- 
pleted, the free extremity of the bandage is most easily 
confined by a pin inserted transversely, or if parallel with 
the length of the bandage, the pin should be introduced 
with its point towards the free end of the roller, otherwise 
it is liable to be drawn out by the constant strain of the 
bandage upon it. When the part to which the bandage 
has been applied is very small in circumference, and the 
bandage itself very narrow, the extremity of the latter 
may be conveniently attached by slitting it longitudinally 
through the middle, and tying the ends around the part ; 
as, for example, the finger or toe. 

Sometimes the roller may be wetted previous to its ap- 
plication, as, for instance, when it is used to confine the 
band to which the pulleys are attached, in the process for 
reducing a dislocation; the band is thus more firmly se- 
cured than when a dry roller is employed. But in ordi- 
nary cases of bandaging, a wet roller should not be used, 
Jbr as it dries, it shrinks and produces a much greater de- 



THE ROLLER, OR SIMPLE BANDAGE. 



73 



gree of pressure upon the soft parts than is consistent with 
safety. 

In some cases it may be advisable to saturate the ban- 
dage with starch which, when it has become dry, forms a 
stiff, firm casement. A more particular mention of this, 
constituting what is generally called " the immovable 
dressing," will be made hereafter. 

The simple bandage receives different appellations ac- 
cording to the mode of its application, or the direction 
which the roller is made to assume ; and again, with re- 
ference to the object to be accomplished by it. Under the 
first division we have the circular, the spiral, the crossed, 
the spica, and the recurrent bandages. The second divi- 
sion embraces the uniting, the dividing, the compressing, 
the expelling, and the retaining bandages. 

1. The circular, is that of which the folds are hori- 
zontally disposed, or nearly 



so ; each successive fold al- 
most completely overlap- 
ping that which preceded 
it. (Fig. 14, a.) 

2. The spiral ascends ob- 
liquely around parts more 
or less conical in form, each 
fold of the roller applying 
itself smoothly and flatly to 
the surface. Sometimes the 
edges of the roller overlap 
each other at each succes- 
sive turn, when the bandage 
is termed by the French, 
"en doloires;" sometimes a 
space intervenes between 
the folds, in which case it is 
termed " rampant:" fig. 14, c 



Fig. 14. 




74 THE ROLLER, OR SIMPLE BANDAGE. 

and b. If a limb, or any other part of irregular form, is 
to be bandaged in its length, it will be impossible to cover 
its surface wholly, and at the same time to make equable 
pressure upon it at all points, by simple spiral turns : one 
of the edges of the roller will compress the surface more 
or less tightly, while the other will be loose. In order to 
obviate this difficulty it is necessary to reverse the turns of 
the roller, from time to time as the varying form of the 
part may require : fig. 14, d. Some considerable practice 
is needful to enable the dresser to make these reverse 
turns rapidly and neatly. The object is to reverse the re- 
lative positions of the edges and surfaces of the bandage, 
whereby its superior edge shall become the inferior, and 
the external face the internal. To accomplish this end 
properly, the spiral should be discontinued so soon as the 
bandage ceases to apply itself smoothly and flatly to the 
surface ; at this point two or more fingers of the left hand 
should be laid upon the roller at its superior edge, and the 
right hand, in which the cylinder is held as before directed, 
and which until now has been kept supine, should be pro- 
nated, while the body of the roller, thus reversed, is suf- 
fered to apply itself, without traction, partly upon the pre- 
ceding fold, and partly upon the surface which is to be 
covered ; then the cylinder is carried around to the oppo- 
site side of the limb, and the process just described re- 
peated. " The hand should press tightly upon each re- 
verse to flatten and equalize it. (Fig. 15.) 

" Two precautions are to be observed in applying the 
reversed bandage ; one is, not to unroll, in making the 
angle, more of the band than is absolutely necessary ; the 
other, to carry the angles upwards in a perpendicular line, 
and always far from the part affected," in order that the 
increased thickness of the bandage at the angle or fold, 
shall not produce a corresponding pressure and indentation 
upon the diseased or injured surface. (Cutler, p. 25.) Each 



THE ROLLER, OR SIMPLE BANDAGE. 



75 



Fig. 15. 




Fig. 16. 



successive turn of the roller should overlap from one-third 
to one-half of that which preceded it, the edges being 
made, as far as possible, parallel with each other. 

3. The crossed bandage is 
made by giving the turns of 
the roller the form of the figure 
8, as is exemplified in the an- 
nexed drawing (fig. 16), in 
which the bandage is supposed 
to be applied to the bend of the 
arm after the operation of 
phlebotomy, to compress the 
incised vein. 

4. " When the turns of the 
roller cross each other in the 




76 THE ROLLER, OR SIMPLE BANDAGE. 

form of the Greek lambda, and leave the band about one- 
third discovered, the A's being applied upon each other, 
the bandage receives the name of spica ; fig. 14 e : it is said 
to be ascendant when the doloires are directed towards 
the superior part of the member, and descendant when 
they regard inferiorly." (Cutler, p. 25.) 

5. The recurrent bandage is applied to the head more 
frequently perhaps than to any other part. It derives its 
name from the fact that the roller, after covering a certain 
portion of the surface, is reflected in its course and brought 
back to its original point of departure, at which it is again 
reversed towards the opposite point. This process is con- 
tinued until the entire surface is covered ; each successive 
fold overlaying one-third, or more, of that which preceded 
it, and being confined at its point of reflection, temporarily 
by the fingers, and permanently by pins or by a circular 
turn of the roller, when the bandaging is completed. It 
forms an exceedingly neat and beautiful dressing. 

The same bandage is employed as an envelope to stumps, 
after amputation, for the purpose of retaining the other ap- 
plications which have been made. 

1 . The uniting bandage, as it has its almost exclusive ap- 
plication to the treatment of wounds, will be considered 
when that class of affections are treated of. 

2. The dividing bandage is employed in the treatment 
of burns and granulating surfaces, where there has been 
much loss of substance, and where unsightly cicatrices are 
liable to be formed, and deformities from the approxima- 
tion of opposed surfaces. The object of this bandage is, 
to obviate such apprehended difficulties by maintaining a 
proper separation of the parts : thus, for example, when the 
anterior face of the neck has been deeply injured by a 
burn, the lower jaw and the head should be prevented from 
being drawn towards the chest, as the ulcer cicatrizes, by 



THE ROLLER, OR SIMPLE BANDAGE. 77 

means of a dividing bandage, having its point d'appui 
around the shoulders and in the axillae. It is generally 
formed of the simple roller. 

3. The compressing bandage, as may be inferred from its 
name, is employed to exercise pressure upon a superficial, 
or a deep-seated, part. Sometimes the roller is used alone, 
sometimes its action is assisted by a compress. 

4. The expelling bandage, like the one last mentioned, 
consists of a roller, generally applied over a compress. It is 
employed to facilitate the expulsion of fluids from morbid 
cavities and canals. 

5. The retaining bandage is used to confine dressings 
in place, as also parts of the body which, having become 
removed from their natural positions, are replaced. 

6. The knotted bandage is sometimes advantageously 
employed to arrest bleeding, particularly of the temporal 
artery ; it will be described hereafter. 

The ability skilfully and neatly to apply and adjust the 
roller, is of very great importance to the surgeon ; and the 
time which the young dresser devotes to its acquisition is 
well spent. It can only be gained by frequent practice ; 
verbal descriptions, and the best executed illustrations, 
should be considered merely as guides and aids ; they 
cannot impart practical skill, any more than the perusal of 
volumes on anatomy, to the exclusion of dissections, can 
render the student acquainted with the mysterious con- 
struction of his material frame. Let each one, therefore, 
spend a few leisure moments every day, with some com- 
panion, in the practical application of the roller : at first, 
reference to some book on bandaging will be necessary, 
but after a certain degree of skill has been acquired, the 
volume may be laid aside ; the student's good sense, and 
the familiarity which he has already gained with the mode 

of bandaging, combined with his knowledge of the par- 

7# 



78 COMPOUND EANDAGES. 

ticular object to be attained in each case, will be his best 
guides and his best adviser. 



SECTION II. 

COMPOUND BANDAGES. 

These are intended to fulfil some especial indication, 
which owing, it may be, to the peculiar conformation of 
the part or parts involved, cannot be so well attained by 
the simple roller. They are formed of one piece, or many 
pieces, of muslin, or of some other material, to which are 
given a shape and conformation varying according to the 
judgment of the dresser. There are some bandages, 
however, so commonly made use of, that they require 
particular description. Such are the crucial, or as it is 
generally called the T bandage ; the invaginated ; the 
many-tailed, or the split; the laced; the sheath, and the 
suspensory bandages. 

1. The T bandage derives its name from its shape. It 
consists of a horizontal band to which is attached another 
at about its middle, having a vertical direction, perpen- 
dicular to the first ; when there are two vertical bands, it 
forms the double T bandage. The length and breadth of 
the strips vary with the dimensions of the part of the body 
to which the bandage is to be applied, and the particular 
end which it is expected to secure. Sometimes, as for 
example, when it is employed to retain dressings upon the 
hand, one of the bands is perforated to admit of the inser- 
tion of the fingers. 

2. The invaginated bandage is used to approximate the 
edges of wounds, or fragments of bone, as in fracture of 
the patella. It is made in two different ways, according 



COMPOUND BANDAGES. 79 

to the indication to be fulfilled by it. Thus, if the object 
be to draw together the lips of a longitudinal wound of a 
limb, a roller should be selected corresponding in width to 
the length of the wound, and long enough to be passed 
several times around the limb. At its free extremity it 
should be slit into two or more tails of a convenient length, 
and corresponding fenestras be made in the band at a dis- 
tance from the end rather greater than the circumference 
of the limb. In its application, the undivided portion of 
the band should be placed opposite to the wound, and the 
tails passed through the fenestras, thus surrounding the 
limb ; then, with a compress placed near each lip of the 
wound, its edges should be gently but accurately approxi- 
mated, and retained in apposition by several turns of the 
roller. For an illustration of this, see the Chapter on 
Wounds. 

The invaginated bandage for transverse wounds, frac- 
ture of the patella, &c, is made upon the same principle 
precisely; it consists of two bands of convenient length 
and width, and of two rollers. Slits, as in the other ban- 
dage, are made at one end of one of the bands, and cor- 
responding fenestras near one extremity of the other ; then, 
by means of the rollers, firmly attach the bands to the 
limb, the one above and the other below the wound, or the 
point of fracture, and having passed the tails of one through 
the fenestras of the other, draw the divided parts together, 
and confine them in this position by successive turns of 
the roller. If necessary, compresses may be used, as in 
the other case. 

3. The split or tailed bandage consists of a piece of 
muslin, or of some other fabric, divided at its extremities into 
a convenient number of tails, leaving the central portion of 
the band entire. Or a piece of muslin of the proper di- 
mensions may be selected, to each extremity of which 



80 COMPOUND BANDAGES. 

bands of suitable length and width shall be attached. 
Constructed after either method, this bandage is very use- 
ful and convenient in confining dressings. 

A very elegant modification of this bandage consists of 
a number of strips, varying in width from two to four 
inches, generally, and sufficiently long to extend about once 
and a half around the affected part, as the leg: these strips 
are so placed upon each other, successively, that each has 
about one-third of its width covered by that which suc- 
ceeds it in the order of super-position, commencing from 
above. The strips, so arranged, may be attached in mass 
along the centre, by means of a needle and thread, thus 
constituting the bandage of Pott, or they may remain un- 
connected, forming the bandage of Scultetus ; the last pos- 
sesses this great advantage over the other, that any strip, 
or strips, which may have become soiled, can readily be 
withdrawn, without deranging, or removing, the others, by 
simply pinning the fresh band to the extremity of that 
which is to be rejected, and drawing it to the situation 
occupied by the latter in the bandage. 

These divided bandages form very light retaining and 
compressing dressings, and present an exceedingly neat 
and elegant appearance, when carefully adjusted. That 
of Scultetus is the one most frequently used. 

4. The laced bandage is made of some more or less 
elastic material, as buckskin, flannel, or caoutchouc, so 
shaped as to correspond accurately to the contour of the 
part to which it is to be addressed, and retained in situ by 
means of straps and buckles, or cords passed through a 
series of eyelet-holes, ranged along the edge of each flap. 

The laced bandage may be advantageously applied to 
any part of the surface, upon which a constant and equa- 
ble pressure will be useful; its most frequent employment, 



COMPOUND BANDAGES. 81 

however, is around the joints, in some chronic affections, 
and on the leg in case of varicose veins. 

A very good substitute, in many instances, for the true 
laced or buckled bandage will be found in a knit woollen 
band of suitable width, having its two extremities firmly 
sewed together, thus forming a circlet somewhat less in 
circumference than that of the affected part, and capable, 
thereby, of imparting firm and elastic pressure around it. 
Or a similarly shaped band of gum-elastic cloth may be 
used, with care to protect the skin from its irritating effects 
by lining it with linen, or by inserting a piece of linen, or 
silk, between the skin and the band. 

5. The sheath comes to hand already prepared for use, 
in the fingers of a glove ; or when a larger envelope is 
needed, it may be easily made after this pattern, of any 
suitable material. It is serviceable as a means of retaining 
applications upon the fingers, toes, or penis, and will be 
found to be much better adapted to this purpose than a 
narrow roller, which cannot be very neatly and conve- 
niently arranged upon these parts, owing to their situation 
and size. 

6. The suspensory bandage is intended to afford support 
and protection to particular parts, as the nose, penis, or 
scrotum. In its simplest forms its preparation is easy, 
being made of a piece of muslin or linen of convenient 
shape and dimensions, and having bands or pieces of tape 
attached to it, for the purpose of retaining it in position. 
In the stores in which surgical apparatus is sold, suspensory 
bandages for the scrotum will be found very elegantly made 
of network. 



82 mayor's system of bandaging. 



SECTION III. 
m. mayor's system of bandaging. 

Struck with the little change and improvement effected 
during the preceding half-century, in that branch of sur- 
gery which is the subject of this volume, and aware of the 
difficulty often experienced, in some situations and circum- 
stances, in securing a constant supply of the materials or- 
dinarily employed in surgical dressings, M. Mayor, Chief- 
Surgeon to the Hospital of Lausanne, Switzerland, has 
originated and developed a new system of bandaging. In 
the year 1832, he published a treatise on this subject en- 
titled, " Nouveau Systeme de Deligation Chirurgicale," 
which has now passed through three editions. The object 
which M. Mayor had in view in his investigations was, 
" To discover some simple means, easy of application, al- 
ways at hand, or readily procurable, and well adapted to 
serve as a substitute for charpie, compresses, cushions, 
bands, bandages, and ligatures, which surgery requires 
for all sorts of dressings." His researches and practical 
experience have at length led him to the conclusion, that 
he has succeeded " in reducing, as far as is practicable, all 
kinds of apparatus to their simplest form, by associating 
them under one common principle; so that the different 
parts of such apparatus, and the materials for all dressings, 
will be found to be so common and of such nature, that 
they may be always, or nearly always, at the disposition 
of the surgeon, and of all other persons, and in the absence 
of the practitioner, maybe readily applied, after some little 
instruction, by the first comer." (Op. cit. 3d ed. p. 16 of 
the Introduction.) 

The whole '- materiel' of M. Mayor's system of ban- 



mayor's system of bandaging. 83 

daging may be reduced to a single square piece of muslin, 
or other suitable fabric ; or, in the absence of this, an ordi- 
nary pocket handkerchief, or a square cravat. From this 
primary form he makes four others, which constitute his 
whole array of bandages ; these are the oblong band, made 
by folding the square several times, until the desired width 
be attained ; the triangular, formed by folding the square 
diagonally ; the cravat, prepared from the triangle, as the 
cravat for ordinary wear is made ; and the cord, which 
is merely the cravat rolled into the form indicated by the 
name. With these simple forms of bandage, M. Mayor 
proposes to replace all the ordinary bands and bandages of 
surgery. He contends that all or nearly all the indications 
which can be fulfilled by the latter, are equally well attain- 
ed by the former, while these are always at hand in town 
and in the country, at sea or on land, in civil and in mili- 
tary practice. 

The above is a mere sketch, an outline, of M. Mayor's 
plan. For a detailed account of it, and for its adaptations 
to particular cases, the reader is referred to the treatise it- 
self. The system is very simple, and its applications may 
be acquired without difficulty. Where the object is merely 
to confine dressings, or to protect parts of the surface, or 
to support a limb, the simple means recommended and 
employed by M. Mayor will probably be found perfectly 
efficacious ; but in the treatment of fractures, and in cases 
requiring well-regulated and firm compression, the author 
is inclined to think that they cannot be advantageously 
substituted for the roller and other bandages, ordinarily 
employed, excepting as temporary means, or in the absence 
of the others. In justice to M. Mayor, it must be observed, 
that he himself admits that there are some circumstances 
in which his own system of bandaging will be found less 
serviceable than the other. 



84 mayor's system of bandaging. 

In the different sections on regional bandaging, the au- 
thor will give such of M. Mayor's dressings as seem to him 
to be most worthy of attention. As an admitted system 
for practical adaptation, it is not, according to the most 
accurate information which the author has been able to 
obtain, employed in any country ; he deems it, therefore, 
superfluous to give its details. 



CHAPTER II. 

REGIONAL BANDAGING. 

SECTION I. 
BANDAGES FOR THE HEAD AND NECK. 

1. The recurrent bandage of the head is composed of 
a single-headed roller about five yards long and two inches 
wide. 

Application. — The initial extremity of the roller is placed 
upon the lower part of the forehead, or on the temple, or 
occiput, and confined by a few turns circling around the 
head in a line running from just above the eyebrows to a 
point a little below the occipital protuberance : at the 
middle of this line, as at the forehead, the course of the 
bandage is reversed, and the reversed turn held by a finger 
of the left hand, while the cylinder of the roller is carried 
over the top of the head along the sagittal suture, to meet 
the circular turns at the occiput ; here a reverse is made, 
again, and confined by an assistant, while the cylinder re- 
turns in an elliptical course to the forehead, where it is re- 
tained upon the first reverse by the finger of the dresser. 
In this manner successive reverses are made at the fore- 
head and occiput, and repeated returns of the roller to and 
from these points in elliptical folds, each successive fold 
overlapping about one-third of the preceding, until at length 
the side of the head is completely covered. The other side 
is covered in the same manner by successive folds similarly 

8 



86 



BANDAGES FOR THE HEAD AND NECK. 



Fig. 17. 




overlaying each other, and the bandage completed by cir- 
cular turns firmly applied over the common points of re- 
verse, in front and be- 
hind : to render the dress- 
ing still more secure, a 
single turn of the roller, 
commencing at the mid- 
dle of the last circular, 
laterally, may be passed 
beneath the jaw, to ter- 
minate at the corre- 
sponding point of the 
circular on the opposite 
side. Pins should be in- 
serted in the bandage 
to confine the reversed 
turns, at the forehead 
and occiput, and one also at the extremity of the roller. 
(Fig. 17.) 

Use. — To retain dressings upon the scalp, and to exercise 
moderate pressure where such may be required. 

2. The T bandage of the head is composed of a band 
two yards long and two inches wide, to which is attached, 
at right angles, another strip of the same width and half a 
yard in length. The longer band is then rolled into two 
cylinders. 

Application. — The dresser, taking his station in front of 
the patient, applies the bandelette to the top of the head, 
over which it passes to the nape of the neck, while the 
longer portion of the bandage starting from the middle of 
the forehead, circles around the base of the cranium, on 
each side, to the occiput, where, just beneath the occipital 
protuberance, it meets the vertical portion ; the latter hav- 
ing been crossed, and confined in this position, by the other 
division of the bandage, is reflected over the vertex to the 



BANDAGES FOR THE HEAD AND NECK. 



87 



Fig. 18. 



forehead, where it is retained by the folds of the longer 
band which expends itself in circular turns. 

A double T bandage may be used instead of the single, 
if more convenient ; in either case the course of the limbs 
of the bandage may be more or less varied to suit parti- 
cular purposes. 

Use. — To retain dressings upon the scalp. 

3. The four-tailed bandage of the head is formed of a 
piece of muslin one yard long and six inches wide, split at 
each extremity to within about three inches of the centre. 

Its application may be varied according to the part of 
the head upon which it is intended particularly to act. 

" When the wound is on the forehead, the unsplit portion 
is applied there, and the two upper tails, carried posteriorly, 
are fixed at the back of the 
head ; the lower tails are then 
fastened either upon the vertex 
or beneath the chin, as the sur- 
geon may consider it most con- 
venient. 

" To confine a dressing upon 
the summit of the head, the pos- 
terior tails, (a, figure 18,) are 
brought down and secured be- 
neath the chin ; the anterior tails, 
(b, b,) after being carried to the 
nape of the neck and crossed, 
are fixed before the throat. 

" In applying it to the nape of the neck, the upper tails 
are conducted over the forehead, from whence, after being 
made to cross each other, they are returned, and fastened 
at the occiput ; the lower tails pass round the neck." 
(Cutler.) 

Use. — As the last. 




88 



BANDAGES FOR THE HEAD AND NECK. 



4. The six-tailed, or the bandage of Galen, consists of a 
piece of muslin a yard long, and a quarter of a yard wide, 
split at each extremity, to within three inches of the middle, 
into three portions, of which the central is rather the 
widest. 

Application. Place the unsplit portion, a, of the bandage 
upon the top of the head ; then folding the edges of the 
central, b, tails inwards, so as to give them a triangular 
form, the base of the triangle being at the top of the head, 
draw the tails down over the ears and tie their extremities 
beneath the chin. Reverse the relative position of the 
anterior and posterior tails, bringing the latter, c, to the 
front, where they shall cross each other upon the forehead, 
and be confined : while the anterior tails, d, are drawn 
round to the occiput, are crossed beneath the protuberance, 
and retained, as on the forehead, by pins. (Fig. 19.) 

Fig. 19. 




Use, as the preceding, over which it possesses a supe- 



bandages for the head and neck. 89 

riority in being more secure, and in covering a large sur- 
face of dressing. 

5. The fronto-occipital triangle of Mayor, serves very 
well the purpose of a retaining bandage. Its application is 
very simple : place the centre of the base of a triangle 
upon the forehead, just above the superciliary ridges, while 
the body of the triangle covers the top of the head, the 
apex hanging down upon the back of the neck ; draw the 
tails around the base of the cranium to the occiput, cross 
them beneath the protuberance, and then continue them 
respectively to the temples, or forehead, and confine their 
extremities by pins. The apex of the triangle, overlapped 
at the occiput by the tails, is reflected upon the latter 
and, being continued upwards upon the body, is pinned. 

The occipito-frontal, and the bi-temporal triangles are 
applied in the same manner as the last, excepting that in 
one case the base of the triangle is laid upon one of the 
temporal regions, and in the other upon the occiput. 

Uses, the same as of the bandage of four tails, &c. 
They are much more simple in their application than those 
heretofore described, and may very well supersede them. 

6. The knotted bandage is composed of a double-headed 
roller four yards long and two inches wide, and of a gra- 
duated compress. 

Application. Place the compress over the wounded 
artery, and apply upon it the body of the roller ; then con- 
duct the heads around the cranium, one over the brow, 
and the other over the occiput, to cross each other at the 
opposite temple, whence they are returned to the compress ; 
on reaching this point they are twisted upon each other, 
and their courses changed, one mounting over the top of 
the head, the other descending beneath the chin, and both 
made to cross again at the opposite temple, after which 
the same route is continued to the compress, where a 

. . ■ 8* 



90 BANDAGES FOR THE HEAD AND NECK. 

second twist is effected and the course of the roller changed 
to the horizontal direction, as at first; again the heads cross 
each other upon the temple of the sound side, the compress 
is again reached, and a third twist made, after which the 
vertical course of the roller is resumed, and the bandage 
completed by a few circular turns. 

Use. To arrest hemorrhage from the temporal artery. 
This somewhat complicated bandage may be very pro- 
perly superseded by a simple roller, and a compress which 
shall be retained and pressed upon the bleeding vessel by 
a few circular turns. 

7. The four-tailed bandage of the chin is composed of a 

strip of muslin a yard long and three inches wide, and 

split longitudinally from each extremity, so as to leave but 

three inches of the central portion of the band undivided. 

Application. Place the middle of the band upon the 

chin, and carry the two upper tails, a, a, 

lg ' ' along the base of the lower-jaw around 

to the nape of the neck, where they 

are crossed, and afterwards conducted 

along the base of the cranium to the 

forehead, and there secured. The lower 

tails, b, b, ascend over the base of the 

jaw and the sides of the face, in front 

of the ears, to the top of the head ; here 

they cross each other and then descend, 

each on its respective side, to the base 

of the jaw, and are confined beneath the chin, (fig. 20.) 

To increase the pressure exercised by this bandage, a 
compress may be applied upon any desired point. 

Use. To retain dressings upon the chin ; it is also used 
in fractures of the lower jaw, and in dislocations of its 
condyles after reduction. For the same purposes the ban- 
dages for fracture of the lower jaw invented by Drs. 




BANDAGES FOR THE HEAD AND NECK. 



91 



Barton and Gibson, of this city, may also be applied. (See 
fractures of Lower Jaw.) 

8. The T bandage of the ear is formed of a horizontal 
limb two yards long and two inches wide, and of a ver- 
tical strip of the same width and half a yard in length. 

Application. Place the vertical limb upon the ear, and 
exhaust the horizontal band in circular turns around the 
base of the cranium, passing just above the ear and over 
the forehead and occiput ; then conduct the vertical limb 
beneath the jaw, up over the opposite side of the face and 
the top of the head to the point whence it started, and con- 
fine its extremity to the horizontal band. 

Use. To serve as a means of retaining dressings upon 
the ear. 

9. The double T bandage of the nose is composed of a 
band one yard long and half an inch wide, upon the middle 
of which are attached at moderately acute angles, and at 
the distance of one inch from each other, two other strips 
half a yard long and of the same width as the first. 

Application. The middle of the horizontal band is placed 



upon the upper lip, and its extre- 
mities are conducted below the lobe 
of the ear on each side to the nape 
of the neck, where they are tied in 
a bow-knot. The other strips are 
then carried obliquely upwards over 
the top of the head, crossing each 
other at the root of the nose ; hav- 
ing reached the occiput, they are 
inserted beneath the horizontal 
band, over which they are reverted 
upon the back of the head and 
confined, (fig. 21.) 

Use. To retain dressings upon the nose. 



Fig. 21. 




92 BANDAGES FOR THE HEAD AND NECK. 

10. The sheath of the nose is thus prepared: " A piece 
of linen is cut into a triangular form, of a sufficient size to 
cover the nose, with two holes perforated near the inferior 
angles to correspond with the nostrils ; a triangular portion 
is cut out from the superior angle of this, the apex of which 
looks downwards upon the median line of the nose, and 
the divided edges are sewed together : thus a sort of bag 
is formed capable of exactly lodging the nose. To the 
lower part of the bag is stitched a narrow band, half a 
yard long and half an inch wide, and to the summit a 
second band of like dimensions. 

" Application. The bag is applied upon the nose : the 
surgeon lays hold of the inferior tails and, passing them 
beneath the ears, ties them in a bow upon the nape of the 
neck ; he then conducts the superior tail along the sagittal 
suture as far as the transverse band, under which he 
passes it, reflecting the end upwards to secure it upon the 
descending portion." 

Use. The same as of the foregoing. (Cutler, p. 61.) 

11. A simple bandage for both eyes may consist of a 
strip of muslin two inches wide, and three feet long, of 
which the central part is placed upon the eyes, and the 
extremities tied upon the occiput. 

Use. — To retain dressings upon the eyes. 

If the object be merely to protect the eyes from the light, 
without exercising any compression upon them, it may be 
very conveniently attained by attaching to each side of a 
piece of muslin, or of green silk, of sufficient length and 
width to cover the eyes, a piece of tape, and ihen tying 
the two upon the occiput. Or the silk, or muslin, may 
be inserted beneath the lower edge of a strip which passes 
just above the superciliary ridges, around the base of the 
cranium to the occiput, where its extremities are tied. By 
this latter arrangement cold or warm lotions may be ap- 



BANDAGES FOR THE HEAD AND NECK. 



93 



Fig. 22. 



plied to the eyes, or to one eye only, simply by saturating 
the pendulous flap, made in this case of linen. 

12. The monocle, or bandage for one eye, consists of a 
single-headed roller four yards long and two inches wide. 

Application. — Two circular turns are made around the 
head, crossing the forehead and occiput, after which the 
course of the roller is somewhat ^depressed, traversing the 
nape of the neck and passing beneath the ear of the affected 
side, to ascend obliquely towards the affected eye, which it 
crosses diagonally ; continuing the same 
direction, it mounts over the forehead 
and side of the head, crossing the top of 
the parietal suture, to descend again to 
the nape of the neck, from which point 
it renews its course, as just described. 
Two or three successive turns are thus 
made obliquely around the head, in the 
form of doloires presenting inferiorly, 
a, a, a ; and the bandage is then termi- 
nated by circular sweeps around the 
forehead and occiput, b, b, (fig. 22.) 

Use.— To confine dressings upon the eye. 

13. The invaginated bandage for the lip consists of a 
double-headed roller, from 




two to three yards long, and 
three-fourths of an inch wide, 
and of two small compresses. 
Application. — Place the 
body of the roller upon the 
forehead, and conduct the 
heads, on each side respec- 
tively, around the cranium 
to the nape of the neck ; cross 
them at this point, and then 
carry them beneath the ears 



Fig. 23. 




94 



BANDAGES FOR THE HEAD AND NECK. 



to the upper lip, over the compresses previously placed 
nea r to, and parallel with, the edges of the wound ; make a 
longitudinal slit in one of the tails, opposite the centre of 
the lip, and through it pass the other head ; make, very 
gently and gradually, a sufficient strain upon the heads of 
the roller, and conduct them again to the nape of the neck, 
and thence to the forehead; repeat this process until the 
requisite support is acquired for the lip, and then confine 
the extremities of the roller, in the customary manner, 
(fig. 23,) 

Use. — To approximate the edges of transverse wounds 
of the lip, and to give support, also, to the hare-lip suture, 
or to replace it after the withdrawal of the pins. 

14. A sheath for the tongue has been contrived by Pibrac, 

to serve as a means of confin- 
ing it, in some measure, when 
wounded. It consists " of a 
little purse, a, for enclosing the 
point of the tongue, having at- 
tached to its base two silver 
wires, which are to be bent 
underneath the chin ; to this 
frame two ribands are append- 
ed, which pass from the chin 
backwards, beneath the ears, 
to the nape of the neck, and 
thence ascend to be tied across 
the forehead." (Velpeau, op. 
cit, vol. i. p. 198.)— (Fig. 24.) 
15. The mask for the face 
is made of a piece of muslin, 
or linen, as large as the face 
itself, having apertures cut in it to correspond with the 
eyes, nostrils, and mouth, and a strip of muslin attached to 
each angle. 




BANDAGES FOR THE HEAD AND NECK. 95 

Application. — Place the mask upon the face so that the 
apertures shall be accurately adapted to the parts for which 
they were intended; carry the superior strips along the 
base of the cranium to the nape of the neck, cross them 
there, then conduct them round to the chin and tie them 
upon the mask ; cross the inferior bands also upon the nape 
of the neck and terminate the bandage by knotting them 
upon the forehead. 

Use.- — To serve as a simple covering to the face, and to 
confine dressings upon it. 

16. The cervical cravat of Mayor consists simply of a 
triangular piece of muslin, or an ordinary handkerchief, 
folded to the form of a cravat. 

Application. — Place the centre of the cravat opposite 
the larynx, the side of the neck, or the back of the neck, as 
may be most proper, and tie its extremities at the opposite 
point. 

Uses. — To retain dressings. 

A simple piece of muslin or flannel is often used as a 
retaining band, in this region. The objection to such an 
application, as commonly prepared, is that it soon becomes 
rolled, and ceases to cover the part properly. This diffi- 
culty may be obviated by a simple method : take a piece 
of flannel or muslin, rather longer than the circumference 
of the neck, and wide enough to cover it completely; fold 
it upon itself in its length, and cut from its anterior border, 
while folded, a triangular piece of which the base presents 
upwards ; then sew the cut edges together, and unfold the 
band, which has thus acquired the form of a common stock, 
and will not become corded when worn upon the neck. 
Its extremities should overlap each other, and be confined 
by pins, posteriorly. 

17. The flexor bandage of the neck, which appears to 
be the moet secure, and at the same time the most simple 



96 



BANDAGES FOR THE HEAD AND NECK. 



Fig. 25. 



and convenient, is the one described by Velpeau, (op. cit. 
p. 203.) 

It consists of a strong muslin cap for the head ; a band 
of stout material, three or four inches wide and about 
three-fourths of a yard long; a roller two yards in length, 
and a circular bandage for the chest, (to be described in 
the next section,) with shoulder and pelvic strips attached. 
Its mode of application varies somewhat with the indi- 
cation it is intended to fulfil. 

If it be employed in the treatment of a transverse wound 
of the neck for instance, it is thus applied : Fix the cap 

firmly to the head by means of 
a band passing under the chin; 
place the undivided portion of 
the strong band above-mention- 
ed upon the top of the head, its 
extremity reposing upon the oc- 
ciput, while the split portion of 
the same band hangs down over 
the face upon the chest ; secure 
it firmly upon the head, in this 
position, by several circular turns 
of the roller, and then, having 
flexed the head to the requisite 
degree upon the anterior face of 
the neck, pin the tails of the band, 
at a convenient distance from 
each other, to the thoracic band- 
age which has been previously 
applied to the chest. 

The same may be used as a 
dividing bandage by simply re- 
versing the relative positions of 
the extremities of the band, the 




BANDAGES FOR THE HEAD AND NECK. 



97 



undivided end being placed upon the forehead, and the split 
portion hanging down over the occiput, so that the head 
may be flexed backwards on the neck, or maintained up- 
right, and so retained by confining the tails of the band 
upon the posterior aspect of the thoracic bandage. Thus 
applied, it will be of advantage in the treatment of burns, 
&c, &c, upon the front of the neck. 

Again, a lateral flexion may be given to the head, as is 
seen in the annexed figure, (fig. 25.) 

18. Professor Jorg's apparatus for the treatment of 
" wry-neck" consists of a pair of leather stays for the 
chest, and of a band or strong circlet for the head. On 
the centre of the stays, in front, is a ratchet-wheel, having 
the edge serrated in such a way as that it revolves only in 

Fig. 26. 




9 



9^ BANDAGES FOR THE TRUNK. 

one direction upon it? axis, the reverse motion being pre- 
vented by a spring pressing against the teeth; a band 

passes upwards from the wheel to be attached to the fillet 
opposite the side of the head : then by turning the wheel 
by means of a key, a, the side of the head is approximated 
to the sternum, so as to counteract or overcome the opposing 
muscles of the anected side. (tig. 26.) 

This instrument may be employed in those cases of 
torticollis in which a considerable degree of force has to 
be exerted and continued for a length of time : where less 
power is requisite, the simpler bandage last-mentioned may 
be used. 



SEC TIG X II. 
BANDAGES FOR THE TRENK. 

1. The dorso-thoracic triangle. (Mayor.) 
Application. — Place the base of the triangle upon the 

anterior, or the posterior, aspect of the chest, as the seat of 
the injury may require, and tie the tails upon the thorax 
either before or behind, while the apex is allowed to repose 
over one of the shoulders, being attached to the base of the 
triangle through the intermedium of a band, if it be not 
sufficiently long of itself to reach this point. 

Use. — To retain dressings upon the anterior or posterior 
face of the chest 

2. Circular bandage with straps, for the thorax. 
Composition. — A strong towel, or an oblong piece of 

muslin folded upon itself to acquire sufficient strength : and 
a band two feet long and four inches wide, split from one 
end through almost its entire length. 

Application. — The napkin is wrapped around the chest, 



EANDAGES FOR THE TRUNK. 99 

its extremities overlapping and pinned ; the undivided ex- 
tremity of the band is then attached in the same manner to 
the middle of this posteriorly, and its tails brought to the 
front, one over each shoulder, and pinned likewise to the 
same. 

Instead of the split band, a triangular piece of muslin 
may be used for the scapulary, by applying its base to the 
back of the neck, and attaching the apex to the thoracic 
bandage posteriorly, while the tails cross, one over each 
shoulder, to be pinned to the bandage in front. 

Again, the thoracic band itself may be rendered more 
efficient, if a constant compression be desirable, by substi- 
tuting straps and buckles, or by lacing it, instead of secu- 
ring it by means of pins. 

Use. — To confine dressings upon the thorax ; to restrain 
the motions of the chest in wounds of this part, or in case 
of fracture of the ribs ; and to secure, by the aid of com- 
presses, the coaptation of the fragments, in the latter injury. 

3. The compressive bandage of Velpeau, consists of a 
roller seven or eight yards long and three inches wide. 

Application. — Let about two feet of the free end of the 
roller hang over the shoulder of the sound side, dow T n the 
back ; then carry the cylinder over the front of the chest, 
below the axilla of the affected side, to surround the thorax 
with several circular turns, and to confine the pendant por- 
tion of the roller; ascend the chest gradually by circular 
folds, each one successively overlapping about two-thirds 
of the preceding ; pass the bandage around the axillae in 
the form of the figure 8, and terminate by circular folds ; 
now, finally, raise the pendant extremity of the roller, and 
crossing it over the shoulder of the affected side, attach it 
to the inferior circular turns by pins (fig. 27). 

Use : as of the preceding ; it has the advantage over the 



100 



bandages for the trunk. 



ordinary circular bandages of the ihorax, in being more 
secure, and less easilv deranged. 



Fig. 27. 







4. The crossed bandage of the chest, or the figure 8 
bandage of the shoulders. 

Composition. — A roller five yards long and two and a 
half inches wide : cotton, or folded muslin, to protect the 
surface at the axillae, and compresses if indicated. 

Application. — If the object be to approximate the shoul- 
ders to the sternum, the folds of the bandage should cross 
in front of the chest. Place the free extremity of the roller 
in one of the axillae, and pass two or three circular turns 
around the thorax; then, the axillae being protected by tLe 
cotton, and the shoulders drawn towards the sternum, by 
an assistant, if necessarv, — traverse the axillae, sav of the 



BANDAGES FOR THE TRUNK. 



101 



Fig. 28. 



left side, and ascend 
over the shoulder 
from behind for- 
wards ; cross the 
front of the chest to 
the right axilla ; 
mount over the right 
shoulder from its pos- 
terior to its anterior 
face ; descend ob- 
liquely over the front 
of the chest to the 
left axilla, whence 
repeat the same 
course as before, un- 
til four or five folds 
have been laid upon 
each shoulder, each 
fold, 



successive told, in 
approaching from the shoulder to the neck, overlapping 
about two-thirds of the preceding. Terminate the bandage 
in circular sweeps around the thorax. (Fig. 28.) 

If it be desired to draw the shoulders from the breast, it 
can be effected by simply reversing the course of the roller, 
crossing the shoulders from before backwards. 

Use. — To aid in the treatment of wounds of the chest, 
by approximating or withdrawing the shoulders from the 
sternum, as may be indicated by the situation of the wound ; 
to effect pressure upon the clavicular regions, and upon the 
sternum, or back, or in the axillas. 

5. Suspensory for the breast. 

Composition. — Double twice upon itself a piece of linen 
ten inches square, and from the free extremity of each 
folded border cut a triangular portion, of which the apex 

9* 




102 BANDAGES FOR THE TRUNK. 

shall terminate in the fold ; then open the square and sew 
the divided edges together ; thus, a concave cap is formed 
adapted to the globular conformation of the breast. At- 
tach a piece of tape, or a band of muslin, to each angle of 
the square. 

Application. — Place the cap upon the mamma and con- 
fine it in situ by tying the two superior bands around the 
neck, and the inferior around the chest below the gland. 

Use. — To support the mamma, and to retain dressings 
upon it. 

6. The triangle-cap for the breast is applied, with the 
base passing just below the mamma, the tails knotted on 
the posterior part of the chest, and the apex ascending upon 
the gland to cross over the shoulder of the same side, and 
be confined to the tails, directly or through the intervention 
of a strip of muslin, or tape. 

Use. — As of the last. 

7. The compressive bandage of one breast. 

It will be found exceedingly difficult, if not impossible, 
entirely to envelope one of the mammary glands by means 
of a roller, which shall be so applied as not to become de- 
ranged very soon, and yet to leave the sound breast free ; 
but such a concurrence of conditions is frequently desira- 
ble. To fulfil these indications, the following bandage may 
be employed. 

Composition. — The same as of the suspensory of the 
mamma, described above, the degree of concavity of the 
cap being proportioned to the volume and convexity of the 
gland ; graduated compresses. 

Application. — Place the compresses upon such points of 
the gland as require most pressure, and cover the whole 
with the cap ; then pass one of the superior bands over the 
shoulder of the sound side, and the other beneath the axilla 
of the side affected (the surface being protected, if neces- 



BANDAGES FOR THE TRUNK. 103 

sary, by cotton interposed between the bands and the skin) ; 
knot the two: draw the inferior bands around the chest, 
beneath the breasts, and tie them either in front or behind. 
The degree of pressure exercised upon the diseased mamma 
can be easily regulated by the size of the compresses, and 
the force with which the bands shall be drawn. 

Use. — To effect a regulated compression of the breast, 
in chronic induration or engorgement of this organ, and to 
obliterate the canals of sinuses, if such exist. 

8. The straight jacket is a garment made of strong but 
light canvass, extending from the root of the neck to the 
upper third of the thigh. It is closed in front, and has 
straps and buckles attached to its posterior borders, or 
eyelet holes worked in them. Along its inner surface 
sleeves are firmly attached, throughout their entire length, 
open above but closed below, and at the proper distance 
from each oiher to correspond with the arms; opposite the 
wrists, a slit may be made through the jacket, to enable the 
professional attendant to feel the pulse of the patient; 
shoulder straps should be attached to the superior border 
of the canvass, to prevent the possibility of the jacket slip- 
ping down, from the efforts of the patient. 

Application. — Insert the arms of the patient into the 
sleeves, and having nicely adapted the jacket to the body, 
draw its borders together behind, and confine them by the 
straps and buckles, or by lacing. 

Use. — To assist in the restriction of the insane, or of 
those who are unmanageable from any cause. 

A very convenient substitute for the straight jacket, and 
one which, while it is equally secure, is less irksome to the 
patient, may be found in a pair of leather mittens, made 
sufficiently loose to be easy to the hand, and slit at the 
wrist so that, after the hand is introduced, one border of 
the wrist-band, in which a fenestra has been made, shall 



104 BANDAGES FOR. THE TRUNK. 

overlap the other, and be confined upon it by an iron loop, 
which passes through the fenestra ; then insert through the 
loop on each wrist a leather strap, having a buckle at one 
end, and enclose the waist therewith. 

9. The body-bandage of the abdomen consists of a piece 
of muslin or linen folded to an oblong shape, a foot or more 
in width, and long enough to envelope the abdomen ; and 
of two narrow straps sewed to its inferior posterior margin, 
to serve as thigh-straps. 

Application. — Place the centre of the bandage upon the 
median line of the loins, and bring its extremities round to 
the front of the abdomen, where they should be overlapped 
and pinned; then draw 7 the thigh-straps to the front along 
the perineum, and attach them to the anterior part of the 
bandage. 

Use. — To retain surgical dressings, to give support to 
the walls of the abdomen, and to exercise pressure thereon, 
as in umbilical hernia ; in the latter case a graduated com- 
press should be employed to assist the compressive action 
of the bandage. 

There are many cases, however, in which a bandage 
formed of a plain piece of muslin, will not support the walls 
of the abdomen sufficiently well. In order to effect this 
object more satisfactorily, an apparatus should be made 
resembling the corsets of ladies; adapted to the conforma- 
tion of the belly, and rendered firm, and yet elastic, by the 
introduction into its folds of strips of whalebone. Its infe- 
rior margin in front should be curved, to correspond with 
the shape of the lower part of the abdominal parietes, so 
that, by being properly laced in front or behind, either a 
uniform pressure, diffused equally over the whole surface, 
can be effected, or a more partial action may be exerted 
in a particular direction. 

An apparatus of this sort will be found applicable to many 



BANDAGES FOR THE TRUNK. 



105 



cases: in umbilical hernia, in ascites, in pregnancy, and 
in other instances of abdominal distension, a very agree- 
able support will be afforded by its use ; and very consi- 
derable, if not complete, relief will be given to symptoms 
simulating, and sometimes, perhaps, depending upon pro- 
lapsus uteri, or other displacements of this organ ; such, for 
example, as dragging pain and weight in the pelvis, a 
sense of exhaustion, of " falling-in of the belly," of faint- 
ness, &c, &c. 

The annexed drawing of an apparatus of this kind, is 
copied from Vel- 
peau, (fig. 30.) 

10. The posterior 
pelvic triangle, of 
Mayor, is applied 
with the base along 
the top of the sacrum, 
and the apex de- 
pending over this 
bone: the tails are 
brought round to the 
front of the abdomen 
and knotted, and the 
apex passed between 
the thighs, along the 
perineum, and pubis, 
to be attached to the 
tails. 

Use. — To retain 
dressings upon the sacrum and perineum. 

11. The anterior pelvic triangle has the base applied to 
the abdomen just above the pubis, while the apex passes 
from before backwards between the thighs, to be attached 
to the tails which are tied upon the sacrum. 




100 



BANDAGES FOR THE TRUNK. 



Use. — To confine applications to the pubis or genitals, or 
simply to cover these parts. 

12. The triangular bandage for the groin is composed of 
a piece of muslin of a triangular shape, and sufficiently 
large to extend from the median line of the abdomen to the 
fold of the groin: to the base is sewed a band long enough 

to pass around the abdo- 



Fig.3 l. 




men, and to the apex an- 
other band of about the 
same length. 

Fig. 32. 




Application. — Place the triangle upon the groin, the apex 
pointing downwards ; tie the superior band around the 
waist, and bring the inferior round the thigh, from before 
backwards, to be pinned to the first, opposite the centre 
of the base of the triangle. (Fig. 31.) 

Use. — To retain dressings upon the groin. 

13. The cruro-inguinal triangle, of Mayor. 

Application. — Dispose the base, a, a, so that it shall run 
obliquely from the summit of the affected groin to the edge 
of the iliac crest of the opposite side, the apex pointing ob- 



BANDAGES FOR THE TRUNK. 



107 



liquely downwards along the groin ; wrap the inferior tail 
around the thigh of the affected side, from behind forwards, 
and pin its extremity to the body of the triangle, at b ; to 
the superior tail attach a band, c, and carry this around 
the loins to the affected side, down along the fold of the 
groin, d, d, crossing the body of the triangle, and the apex, 
— pinning the latter to it, — around the posterior and outer 
aspects of the thigh, to be confined at e. (Fig. 32.) 
Use. — As of the last. 
14. The spica of the groin. 

Application. — Place the initial extremity of a roller seven 
yards long and two inches wide, upon the sound side of the 
pelvis, between the anterior spines of the ilium, and confine 
it by circular turns passing around the body, from before 
backwards. After having made two or three circular 
turns, carry the head of the roller obliquely downwards 
over the groin affected, around the posterior aspect of the 
thigh to the ilium again, then across the groin to the opposite 
side of the pelvis, from which it returns to the affected side 
and repeats the same process several times, terminating at 
length by one or two circular turns. Each successive 
layer of the roller should leave exposed about one-third of 
that which preceded it; see fig. 14, e, e. 

Use. — To confine dressings upon the groin, and to exer- 
cise some degree of compression upon it, as in chronic 
glandular enlargements and indurations. 

15. The cruro-inguinal cravat, of Mayor, will be found 
a very good substitute for the spica just described, and 
much more simple in its application. 

Place one end of the cravat upon the affected groin, over 
a compress, or not, and conduct the remainder downwards, 
along the groin, to pass between the genitals and the thigh, 
and thus gain the posterior face of the limb ; ascend ob- 
liquely upwards and outwards over the thigh, cross the 
affected groin, and the end of the cravat already spoken of, 



108 



BANDAGES FOR THE TRUNK. 



to the iliac crest of the opposite side ; wind around the loins 
to the ilium of the affected side, pass obliquely downwards 
along the groin, and gain the external face of the thigh, as 
before, where the extremity is to be pinned. 
16. The spica for both groins. 

Application. — Place the initial end of a roller, ten yards 
long and two inches wide, upon the pelvis, as in the single 
spica, and confine it by circular turns running around the 
pelvis from right to left, (this being the most convenient 
course in practice) ; having reached the left side, descend 
along the outer face of the thigh, around it posteriorly, and 
so gain the groin ; then carry the roller upwards over the 
groin to the ilium of the same side, and thence around the 
loins to the opposite groin ; descending this obliquely, pass 
the bandage between the genitals and the thigh, and around 
the limb to mount over its outer face ; cross the right groin, 
and the lower part of the abdomen to the left ilium, and 
then wind around the left groin, and so proceed as before. 
After several turns have been made in this manner, termi- 
nate the bandage by a few circulars around the pelvis. 
Use. — To effect pressure upon both groins. 
The same object may be attained by the use of cravats. 
17. The double T bandage of the pelvis is prepared from 
a band two or three yards long and three inches wide, 
having sewed to it at right angles, and at a convenient 
distance from one extremity, two other strips, distant from 
each other about two inches, each being an inch wide and 
half a yard long. 

Application. — Place the horizontal band so that the ver- 
tical strips shall depend, one on each side of the median 
line of the sacrum. Confine the first by two or three cir- 
cular turns around the body, and draw the vertical bands 
forwards between the thighs, crossing them upon the 
perineum, to be attached to the horizontal strip in front. 



BANDAGES FOR THE TRUNK. 



109 



Use. To retain applications made to the anus, vagina, 
or perineum. 

Instead of two vertical pieces, a, single strip may be 
used, half a yard long and as wide as both the others com- 
bined, slit at its free extremity to near the horizontal 
portion. 

18. The suspensory of the scrotum may be made of 
two pieces of linen or muslin, or of network, of a size 
varying according to the volume of the 
scrotum. In general, they should be each 
" six inches long and four wide; the pieces 
being laid together with exactness, two 
portions are cut out curvilinearly, as shown 
in the wood cut (fig. 33), by dotted lines; 
the divided edges from a to b being sewed 
together, a sort of bag is formed, which 
presents at the middle of its upper part an opening,/, (fig. 
34,) through which the penis passes. A belt, c, two inches 





Fig. 33. 


r 


d 




' \ ' 




/ 


b 


./ 



Fig. 34. 



wide and rather longer than is re- 
quisite to encircle the body twice, 
is then sewed along the upper 
edges of the bag, as from c to d, 
(fig. 33,) to the superior border of 
this belt, at about two inches each 
way from the centre, are attached 
two small loops of tape or riband, 
d, d, fig. 34, and about as far 
again from the centre two mould- 
buttons, e, e. 

" Two bandelettes are next fas- 
tened to the lower angle of the bag, each about half a yard 
long, with two button-holes near their free extremities. 

" Application. The penis being engaged in the triangular 
opening,/, of the bag, and the scrotum perfectly enveloped, 

10 




110 



BANDAGES FOR THE TRUNK. 



Fig. 35. 



the belt is carried round the pelvis, and being returned 
through the loops, d, d, is tied above the pubis ; the two 
bandelettes are then passed between the thighs, to ascend 
from the perineum along the inferior borders of the glutei 
muscles, and buttoned to the belt in front, e, e. 

" Use. — To support and confine dressings upon the scro- 
tum; to serve also as points of attachment for other appa- 
ratus. It is chiefly employed in the treatment of swelled 
testicle, hydrocele, and irreducible scrotal hernia." (Cutler, 
pp. 101-2.) 

19. The suspensory triangle of Mayor. 
Application. — Pass a cravat around the abdomen and 

pelvis, and knot it securely. Ap- 
ply the base of a triangle to the 
under part of the scrotum at its 
origin, and draw the tails upwards 
in front of the cravat, to be reflected 
over its superior edge, between it 
and the abdomen, and tied as re- 
presented in the annexed figure, 
(fig. 35.) Carry the apex of the 
triangle upwards, inserting it be- 
hind the transverse portion of the 
tails, (see fig. 35), between the ab- 
domen and the girdle, to be reflect- 
ed forwards over the superior bor- 
der of the latter and pinned to it. 
Use. — The same as of the last. 

20. Bandage for the penis. 

It is requisite sometimes to make use of some means for 
confining applications upon the penis. For this purpose a 
sheath is the most convenient covering. When, however, 
a certain degree of compression is wished for, the organ 
should be enveloped in circular and reversed turns of a 




BANDAGES FOR THE UPPER EXTREMITIES. Ill 

piece of tape, or some very narrow strip prepared at the 
time. 

For the compressive bandage of the scrotum, see remarks 
in the section on " adhesive plaster." 



SECTION III. 

BANDAGES FOR THE UPPER EXTREMITIES. 

1. The axillo-clavicular cravat, of Mayor. 

Application. — Place the centre of the cravat upon the 
axilla, and draw the tails obliquely upwards over the chest, 
one in front and the other behind, to be knotted together 
upon the clavicle of the opposite side. 

Use. — To confine dressings in the axilla. 

This may be varied a little, and still fulfil the same end, 
by crossing the tails of the cravat upon the shoulder of the 
affected side, — the centre being in the axilla, as before, — 
and then conducting them, one in front of and the other 
behind the chest, to the axilla of the sound side, where they 
are to be secured. 

2. The compound bis-axillary cravat is applied, by ar- 
ranging one cravat in the manner first pointed out above; 
and then placing the centre of a second in the other axilla, 
its tails being conducted obliquely upwards, one before and 
the other behind the chest, to be attached to the tails of the 
first at their point of junction. 

Use. — To retain dressings in both axillae at once. 

3. The crossed bandage of the shoulder and axilla. 
Composition. — A roller eight yards long and two inches 

wide. 

Application. — Confine the initial extremity of the roller 
to the arm of the affected side, by a few circular turns 
passing from before backwards and from without inwards. 



112 BANDAGES FOR THE UPPER EXTREMITIES. 

Then carry the roller obliquely upwards over the shoulder 
of the same side, and downwards obliquely over the front 
of the chest to the opposite axilla. From this point, the 
roller should cross the back obliquely upwards to the 
shoulder of the affected side and, traversing the descending 
turn, regain %he arm from which it started. Several crosses 
may be made in the same manner, and the roller terminated 
by circular sweeps around the arm. 

Use. — To confine applications made to the shoulder, or 
to the axilla, — or to exercise pressure upon these parts, 
which may be aided by the employment of compresses. 

4. For the crossed bandage of both shoulders and axillae, 
see Section II. 

5. A sling for the fore-arm. 

Place the middle of a triangle beneath the fore-arm, with 
the apex towards the elbow ; then carry the extremities 
obliquely upwards, the anterior over the shoulder of the 
sound side, and the posterior over that of the affected side, 
and tie them around the neck. 

To suspend the hand and wrist, an oblong piece of linen, 
or muslin, or a cravat, may be employed and the part 
placed upon its centre ; then tie the lateral portions toge- 
ther, leaving the hand loosely confined, and suspend the 
whole to some convenient part of the patient's dress, or to 
the neck. 

6. The carpo-digito-dorsal triangle, of Mayor. 
Application. — Place the triangle upon the back of the 

hand, its base being upon the wrist, around which the tails 
are to be wrapped and confined ; then having flexed the 
fingers to the proper degree, draw the apex of the triangle 
over them and attach it to the envelope of the wrist. 

Use. — To approximate the edges of wounds in the palm 
of the hand, or on the palmar surface of the fingers ; also 
to prevent the deformities which are likely to occur from 



BANDAGES FOR THE UPPER EXTREMITIES. 113 

the cicatrization of burns on the dorsal aspect of the 
hand. 

7. The palmo-digito-brachial triangle. 

Application. — Tie a band around the arm, just above 
the condyles of the humerus ; then place a triangle upon 
the palmar surface of the hand, its base overlaying the 
wrist, around which the tails are wrapped and confined, — 
and reflect the apex over the fingers and back of the 
hand, to be attached to the extremity of the supra-con- 
dyloid band. 

Use. — In transverse wounds of the dorsal aspect of the 
hand and fingers, and in burns of their palmar face. 

8. The spiral bandage of the upper extremity is effected 
by the use of a roller, eight yards long and two and a half 
inches wide : compresses if required. 

Application. — Confine the initial extremity of the roller 
upon the wrist by circular turns passing from the radial 
towards the ulnar side, — the hand being supine ; traverse 
the palm and the back of the hand obliquely to gain the 
ends of the fingers, and then return to the fraenum of the 
thumb by simple spiral turns : envelope the ball of the 
thumb and the wrist by folds in the form of a figure 8, and 
ascend the forearm by spiral and reversed sweeps around 
the part. Having reached the elbow, place the arm in the 
proper position ; if straight, continue the spiral and reversed 
turns to the shoulder ; if flexed, cover the elbow with 
crossed folds in the form of the figure 8, and then ascend 
as before. 

Use. — To envelope the arm, and to make uniform, or 
graduated, compression upon it. Great care is necessary, 
especially in case of injury, to avoid exercising too much 
pressure upon the member, as serious inconveniences and 
accidents have resulted from inattention in this respect. 

10* 



114 



BANDAGES FOR THE UPPER EXTREMITIES. 



9. The spica bandage of the upper part of the arm and 
the shoulder. 

Composition. — A roller, eight yards long and two and a 
half inches wide, with compresses for the axilla of the 
affected side. 

Application. — The right arm being the one which re- 
quires the bandage, place the roller upon the upper part of 
the arm, so that about two feet of its free portion shall de- 
pend from the outer side of the member ; confine it in this 
position by one or two spiral and reversed turns passing 
around the limb from its outer towards its inner face; then 
carry the roller up over the outer aspect of the shoulder, to 
descend obliquely across the chest, in front, to the axilla of 

the sound side, and return 
to the affected shoulder 
along the back of the 
chest: descend into the 
axilla along the front of 
the shoulder, and then 
mount over its posterior 
face to traverse the front 
of the chest, as before ; 
having thus laid several 
folds, secure the terminal 
end of the roller by a 
pin ; now bring the initial 
portion of the bandage, 
which was left depending 
from the posterior face 
of the arm, to the front, 
over the anterior fold of 
the axilla and the shoulder, and around the back of the 
neck, to terminate in front of the chest, on the sound side, 
(fig. 36.) 




BANDAGES FOR THE UPPER EXTREMITIES. 115 

Use. — To exercise compressing force around the upper 
part of the arm and shoulder. 

10. The spica bandage of the thumb. 

Composition. — A roller three yards long and one inch 
wide. 

Application. — Confine the initial extremity to the wrist 
by circular turns passing from the radial to the ulnar mar- 
gin, the hand being held in a vertical position with the 
thumb above ; now carry the roller from the palmar to- 
wards the dorsal aspect of the thumb, between it and the 
index finger, sweep around the base of the former and the 
wrist to regain the palmar surface of the thumb ; repeat 
this process until the roller is exhausted, and then confine 
its terminal end. 

Use. — To compress the thumb and to restrain its motions, 
as after dislocation. 

A spica bandage may be applied around any of the fin- 
gers, after the same manner. 

11. The gauntlet. 

Composition. — A roller eight yards long and an inch 
wide. 

Application. — Confine the initial extremity to the wrist 
by a few circular turns, then descend to the tip of each 
finger, successively, by oblique sweeps of the roller, return- 
ing in spiral and reversed turns to the metacarpo-phalan- 
geal articulation : terminate the bandage by circulars around 
the body of the hand and the wrist. (Fig. 37.) 

Use. — To prevent the opposed surfaces of the fingers 
from uniting in the cicatrization of burns ; to make general 
compression upon the hand, and to assist in the cure of 
fractures and dislocations of its bones. 

12. The demi-gauntlet. 

Composition. — A roller five yards long and one inch 
wide. 



116 



BANDAGES FOR THE UPPER EXTREMITIES. 



Fig. 37. 



Fiz. 38. 





Application. — The hand being prone, confine the initial 
extremity of the bandage about the wrist by circular turns 
passing from its ulnar to its radial side ; then discontinuing 
the circular at the cubital side, carry the roller obliquely 
across the back of the hand to the radial margin of the 
index finger at the junction of the phalanx with the meta- 
carpus, across the palmar face to the cubital margin, and 
thence around to the radial border of the hand; cross the 
palm to its cubital side, over the back of the hand to the 
index side of the middle finger, around the base of this to 
its cubital aspect and then to the radial border of the hand ; 
so continuing until the root of each finger is covered ; ter- 
minate the bandage by a circular sweep around the wrist. 
(Fig. 38.) 

Use. — A light retaining bandage for the back of the hand. 

13. The triangle cap for the hand. 

Application. — Lay the hand upon the triangle, the base 
overlapping the wrist ; reflect the apex over the extremities 



BANDAGES FOR THE LOWER EXTREMITY. 117 

of the fingers upon the wrist, and secure it in this position 
by wrapping the tails of the triangle around the same part. 
Use. — To retain applications upon the hand, which it 
effects very perfectly and readily. 

14. The cravat bandage for the palm or back of the hand. 
Application. — Place the palm, or the back of the hand, 

upon the centre of the cravat ; reflect the tails upon the 
other surface, and cross them ; after which, tie them about 
the wrist. 

Use. — An effectual and convenient retaining bandage for 
the body of the hand. 

15. The perforated bandage of the hand is made of a 
piece of muslin or linen large enough to envelope the hand, 
having attached to its lower margin a band half a yard or 
more in length and an inch wide, and being perforated 
near its superior border by holes corresponding with the 
fingers. 

Application. — Insert the fingers through their respective 
fenestras and draw the piece over the hand, enveloping the 
latter neatly and accurately ; secure it thus by the band. 

Use. — Same as of the preceding. 

SECTION IV. 
BANDAGES FOR THE LOWER EXTREMITY. 

1. The cruro-iliac triangle, of Mayor. 

Composition. — A cravat, and a triangle. 

Application. — Knot the cravat around the pelvis, passing 
it just below the crest of the ilium ; place the centre of the 
base of the triangle immediately beneath the great tro- 
chanter, encompass the thigh with the tails of the bandage, 
and tie their extremities, or confine them with pins ; then 
raise the apex of the triangle, and inserting it between the 
surface of the body and the cravat which girdles the pelvis, 
reflect it back upon the body of the triangle and pin it. 



118 BANDAGES FOR THE LOWER EXTREMITY. 

Use. — To confine applications made upon the gluteal 
region. 

2. The bandage of Scultetus is described fully in Sect. II. 
Chap. I. 

3. The eighteen-tailed bandage for the lower extremity. 
Composition. — Stitch transversely to a band of muslin, 

of sufficient length and about four inches wide, eighteen 
other strips, three or four inches in width, and long enough 
to make one circuit and a half about the limb; — the centre 
of each transverse band crossing the vertical, and the indi- 
vidual pieces arranged in the same manner as the strips of 
the bandage of Scultetus, which it resembles in its appli- 
cation and uses ; as before stated, it has the disadvantage 
of requiring the removal of the whole, if a single portion of 
the bandage become deranged or unfit for longer employ- 
ment ; hence it is but little used, the other being preferred. 

4. Invaginated bandages for longitudinal and transverse 
wounds of the thigh. For a description of the composition 
of these, consult Sect. II. Chap. I. Their application will 
be illustrated in the chapter on wounds. 

5. The crossed bandage of the knee. 

Composition. — A roller four yards long and two and a 
half inches w r ide. 

Application. — Confine the initial extremity upon the 
thigh, just above the knee, by circular turns sweeping 
around the limb from left to right (of the dresser) ; then 
conduct the roller obliquely across the top of the knee to 
the posterior aspect of the leg, around which a circular 
turn is effected, and the roller made to ascend diagonally 
over the knee, crossing the first oblique : having reached 
the lower part of the thigh, a circular turn is made, after 
which the oblique and circular folds alternate with each 
other in the manner described, and the bandage terminates 
in a circular turn below or above the knee. 

Use. — To exercise compression upon the knee, or to re- 



BANDAGES FOR THE LOWER EXTREMITY. 1 1 9 

tain dressings in this situation. The same object may be 
attained in the popliteal region, by crossing the bandage 
behind, instead of in front. 

It will readily be seen that a triangle, or a cravat, will 
fulfil the same purpose ; the former as a retaining, the latter 
as a compressing bandage, when only a moderate degree 
of force is called for. 

6. Weiss's elastic knee-cap, made of some elastic web 
and lined with India-rubber cloth, or having strips of India 
rubber inserted between its layers, gives a very agreeable 
and sufficiently compressive support to the knee : it is con- 
fined about the joint by lacing. 

As a substitute for this, the elastic bandage made of 
woollen yarn knit, — described with the laced bandage, in 
the second section of the first chapter, — may be employed. 

7. The spiral bandage of the lower extremity. 
Composition. — A roller six yards long and two and a 

half inches wide. 

Application. — This may be accomplished in several 
ways. 

1st. Confine the initial extremity of the roller around 
the ankle, say of the right leg, by circular turns revolving 
from its outer to its inner side : having reached, in the 
second circular turn, the external malleolus, conduct the 
roller across the instep obliquely to the inner side of the 
foot, and beneath the sole to the little toe ; then retrace 
the course, covering the foot with two or more spiral 
turns ; having regained the instep, ascend it obliquely and 
sweep around the leg from the inner to the outer side ; 
thence cross obliquely to the inner margin of the instep, 
wind beneath the sole and the outer side of the foot, in ad- 
vance of the malleolus, mount over the instep to the tibial 
side of the leg, and then conduct the roller to the knee in 
spiral and reversed turns. If the limb be straight, continue 
the same with a fresh roller, if necessary, until the whole 



120 



BANDAGES FOR THE LOWER EXTREMITY. 



limb shall be covered. If, however, the knee be flexed, 
the joint must be enveloped with folds in the form of the 
figure 8, and circular if need be ; then ascend the thigh as 
in the other case, (fig. 14, d.) 

This mode of bandaging the limb is very simple and 
secure ; the only objection to it is that it leaves the heel 
uncovered ; and as this part sometimes swells and becomes 
painful if left exposed while the parts above are protected, 
it behooves the dresser to avoid this difficulty, as in the 
following mode : 

2d. The right leg being selected, confine the initial ex- 
tremity of the roller as above ; then, instead of crossing 
the instep, wind around the inner malleolus, and over the 
ridge of the tendo Achillis, just above its attachment to the 
heel, over the space between the external malleolus and the 
extremity of the heel, and then cross the sole of the foot 
by a single oblique sweep, to the great toe ; cover the foot 
from the toes to the instep by spiral turns, and then wind 
around the inner side of the heel, crossing the space be- 
tween the inner malleolus and the point of the calcaneum, 
over the arch of the tendo Achillis to the outer side of the 

leg, just above the malleolus ; 
now pass over the instep and 
the point of the heel to the 
instep again, and w 7 ind the 
roller in the form of the figure 
8, around the leg, the instep 
and the sole, when having 
conducted the bandage to the 
tibial margin of the leg, 
ascend the limb by spiral and 
reversed turns, (fig. 39.) 

3d. The French spiral, as 
it is termed, differs but little 
from the first. It is usually 



Fig. 39. 




BANDAGES FOR THE LOWER EXTREMITY. 121 

commenced by merely placing the initial extremity upon 
the outer margin of the instep ; (but this is less secure than 
if it is confined around the ankle ;) now wind obliquely 
around the foot to the great toe, and beneath the sole to 
the opposite side ; from this point cover the foot with spiral 
and reversed turns extending as high up on the instep as 
may be consistent with the firmness of the bandage, and 
ascend the leg at once, in spiral and reversed sweeps, 
without enveloping the heel. 

Use. — To restrain the action of the muscles of the leg ; 
to compress the limb uniformly, and to assist in procuring 
the removal of indolent swelling of the soft parts, whether 
caused by serous infiltration, chronic inflammation, or 
otherwise. 

8. Baynton's bandage for the treatment of ulcers. 

This mode of treatment has been already described in 
the first part of the book, in the course of the remarks on 
Adhesive Plaster. For an illustration of its application, 
see fig. 39. 

9. The laced stocking is made of buckskin, or of some 
elastic web. It is formed of two pieces fitted to the shape 
of the limb and sewed together along the back of the leg 
and the sole of the foot : the anterior margins are provided 
with eyelet holes, for the purpose of lacing the stocking 
when applied ; and in order to obviate the inconveniences 
which might arise from the direct contact of the lacing 
apparatus with the skin, a piece of some soft material 
should be sewed along the inner surface of one of these 
anterior borders. 

Use. — To exert a uniform and equable pressure around 
the leg, particularly in case of varicose veins. 

10. An elastic gaiter for the foot and ankle may be very 
well made of India-rubber cloth, lined with linen or silk, 

11 



122 BANDAGES FOR THE LOWER EXTREMITY. 

so contrived as to correspond with the shape of the part, 
and still be elastic : it should be confined upon the foot by 
lacing along the outer side. 

Use. — To support the foot and ankle after sprains of the 
part, or in chronic intumescence from any cause. 



PART III. 

BANDAGES AND APPARATUS EMPLOYED IN THE 
TREATMENT OF FRACTURES. 

CHAPTER I. 

GENERAL CONSIDERATIONS ON THE TREATMENT OF FRACTURES. 

The method by which nature effects the cure of a frac- 
ture is, the formation of what is technically called " The 
Callus ;" the different steps of this process are thus briefly 
stated by Muller, (Physiol., vol. i. p. 454) : — " The inflam- 
mation which ensues immediately after the fracture of a 
bone affects principally the surrounding soft parts, viz. the 
periosteum, cellular tissue, and muscles, which all become 
enlarged and agglutinated together, so as to form a firm 
capsule around the fracture. On the inner surface of this 
capsule there is formed, as a result of the inflammation, a 
semi-fluid substance which gradually acquires more con- 
sistence and becomes traversed by vessels. A similar 
substance is effused by the medullary tissue of the broken 
bone; and this, together with the substance poured out 
by the capsule, at length coalesces, and forms the mass en- 
closed in the capsule and investing the ends of the bone, to 
which the name of * substantia intermedia' has been given. 
This substance acquires a fibrous texture, and fills all the 
space between the bones; while the muscles, cellular tissue, 
and periosteum return to their former normal condition. 



124 TREATMENT OF FRACTURES. 

The inflammation does not affect the bone so soon as it 
does the soft parts ; it commences in it at some little dis- 
tance from the fractured extremities, namely at the part 
where the bone is still invested with periosteum, and at the 
corresponding point in the interior. The bone likewise 
now pours out a gelatinous exudation, in which vessels be- 
come developed, and which continues to grow ; while, on 
the side by which it is connected with the bone, it becomes 
converted into cartilage and bone. This new mass — the 
proper callus, — also occupies to a greater or less extent 
the medullary cavity. On the exterior, its formation is 
continued towards the fractured extremities, till the exuda- 
tions of the two portions of bone meet and unite. Thus is 
formed the primitive callus. 

" In the mean time, the surface of the bone unites with 
the capsule formed by the soft parts and the primitive 
callus, and the margins of the fracture unite with the ' sub- 
stantia intermedia.' Callus, too, is formed, and developes 
itself at the expense of the now ligamentous ' substantia 
intermedia.' Periosteum is formed anew on the external 
uneven surface of the callus. 

" The further changes which the callus undergoes after 
the ends of the bone have united, consist in the restoration 
of the medullary cavity in its substance, and in the change 
of its form. The texture of the callus undergoes the same 
changes as the cartilage of bone in ossification. While it 
is cartilaginous, it contains the peculiar corpuscles of car- 
tilage ; when it ossifies, it assumes the cellular texture of 
bone." 

According to Dupuytren, the period during which the 
provisional callus is being formed continues until the thir- 
tieth or fortieth day. In the subsequent period, the ossifi- 
cation of the cartilaginous intersubstance — " substantia 
intermedia" — takes place not before the fourth or sixth 



TREATMENT OF FRACTURES. 125 

month ; the swelling of the soft parts having been first re- 
moved by absorption, the bony mass filling up the medul- 
lary canal is likewise absorbed, and this cavity restored at 
the end of six to twelve months. 

Now, the aim of the surgeon, in the treatment of frac- 
tures, should be to place and preserve the injured parts in 
such circumstances as shall most conduce to the accom- 
plishment of the reparative processes just mentioned. To 
effect this, three steps are necessary : 
1st. To secure the proper apposition of the fragments, if, as 
is generally the case, the broken ends have suffered dis- 
placement ; 
2d. To retain the fragments in this position ; 
3d. To prevent or remedy any unpleasant symptoms at- 
tending or following the fracture. 

The method by which these indications may be best ful- 
filled claims a brief consideration. 

1. The reduction of the fracture is effected by extension 
and counter-extension, the first acting upon the inferior or 
distal fragment, the last on the superior or proximal. 

There is some diversity of opinion respecting the point 
from which the fragments should be operated upon : sur- 
geons of the French school applying the extending force to 
that portion of the limb which articulates with the inferior 
fragment, and the counter-extension to that with which the 
superior is connected ; while the English make the extend- 
ing force upon the lower fragment itself, and the counter- 
extending upon the upper. 

To each of these plans there are objections and disad- 
vantages attached, if exclusively insisted upon. The argu- 
ment urged by the Continental surgeons against the latter, 
viz. — that, by grasping the muscles which are connected 
with the fragments themselves, the reduction is rendered 
more difficult and more painful, because the muscles are 

11* 



126 TREATMENT OF FRACTURES. 

made to counteract more vigorously the reducing forces, — 
is not really of much weight. For the efforts made to re- 
duce a fracture need never be violent; the force operates gra- 
dually and is exerted mediately or immediately by the hands; 
and, moreover, the muscular contraction with which the sur- 
geon has to contend is induced, probably, by the irritation 
inflicted upon the muscular fibres as the irregular and 
sharp extremities of the fractured bone glide over them, 
during the action of the extending and counter-extending 
forces, rather than by the mere grasping of the muscles by 
the hands ; and it will, therefore, be excited whether the 
forces act upon the broken bone, or upon portions of the 
limb more distant from the seat of injury. If the French 
mode of reduction be practised, the surgeon is obliged to 
overcome the contractile force not only of the muscles di- 
rectly connected with the broken bone, but of those like- 
wise which have their attachments to the more distant 
parts through which he operates. 

In reducing a fracture, the surgeon may, therefore, con- 
sult his convenience as to which mode he shall adopt ; if 
the thigh has been broken, it will be most conveniently re- 
duced by acting upon the pelvis, and the ankle and leg 
just above the ankle ; if the forearm is the seat of fracture, 
the injury may most easily be remedied, and with least as- 
sistance of attendants, by placing this member upon a pro- 
per splint, and operating upon the elbow and wrist, the 
surgeon himself making both extension and counter-exten- 
sion, while the splint, with the forearm resting upon it, is 
supported by his knee, or by an attendant. 

The amount of force employed in the reduction must be 
adapted, of course, to the resistance to be overcome ; it 
should be gradually and steadily exerted. Much assistance 
will be derived from so arranging the position of the limb 
as that the most powerful muscles — those whose contrac- 



TREATMENT OF FRACTURES. 127 

tion is most opposed to the proper restoration of the frag- 
ments, — shall be shortened, and thus rendered in a measure 
quiescent : i. e. the limb should be more or less flexed ; and 
after the reduction of the fracture has been effected, this 
flexed position may be maintained, or the limb may be 
slowly and cautiously straightened, as the views of the 
surgeon, with regard to the permanent position of the limb 
during the treatment, shall dictate. The irritability of the 
muscles may be lessened by the administration of opium, 
and by distracting the patient's attention ffom his injury, 
while the reduction is being effected. 

The extending force should be made in the direction 
which the limb has assumed since the fracture; and then, 
as the proper line is gradually regained, the traction should 
coincide with it. 

As soon as the natural length of the limb has been re- 
stored, the surgeon should adjust the fragments as accu- 
rately as possible. To this step the term " coaptation" is 
commonly applied. It is accomplished by pressing gently all 
around the neighbourhood of the seat of fracture, avoiding, 
as far as may be practicable, all pressure directly over and 
upon the fragments, in order not to give pain, and that the 
soft parts immediately in contact with the splintered ends 
of the bone shall not be wounded and irritated, more than 
may be unavoidable. The points of the fingers should not 
be used, therefore, but the hand should be laid flatly upon 
the part, and very gentle pressure be gradually made from 
side to side. 

2. The fracture having been thus reduced, the aim of the 
surgeon is to maintain the fragments in apposition, until 
consolidation shall have become perfected, in other words, 
to preserve these parts in a state of perfect rest. This can 
be accomplished only by mechanical appliances which shall 
prevent displacement of the fragments arising either from 



128 TREATMENT OF FRACTURES. 

simple muscular contractions, or from external causes, or 
both. There are some exceptional cases from time to time 
occurring, in which, — from the fracture being perfectly- 
transverse, and unattended by displacement of the frag- 
ments, — it may not be absolutely necessary to confine the 
injured part ; but even in such cases, no prudent surgeon 
would neglect to do so, in order to guard against accident 
or violence. 

The mechanical means of retention employed in the 
treatment of fractures consist, of bandages, compresses of 
various forms and sizes, and splints. These will be more 
particularly enumerated and described, when special frac- 
tures are treated of. 

The operation of these retentive means will be much 
aided by a proper position of the limb which is the seat of 
the fracture, — that position, namely, which will relax the 
most powerful muscles, connected with either fragment. 
The question of position will be more particularly referred 
to in the section on the treatment of fractures of the thigh, 
to which it has more especial reference. 

There are some exclusive plans of treating fractures 
which merit description : these are chiefly, — 1st. The treat- 
ment by the " immovable apparatus ;" and 2d. The hypo- 
narthecic method of Sauter and Mayor. 

The first — or the method of treatment by the " immov- 
able apparatus," — seems to have been introduced into 
France from Spain, under the auspices of the celebrated 
Baron Larrey. As employed by this surgeon, the mode of 
its application was to surround the limb — the fracture hav- 
ing been reduced, and the limb placed in the straight posi- 
tion,; — by compresses, of suitable form and dimensions, 
saturated with a mixture of white of egg, camphorated 
alcohol and subacetate of lead, and retained upon the limb 
by folds of the bandage of Scultetus, likewise saturated with 



TREATMENT OF FRACTURES. 129 

the same mixture ; the member was kept completely quies- 
cent until the bandage had become perfectly stiff and firm, 
forming a rigid case around the limb. (Vidal de Cassis, 
Trait, de Pathol. Ext. vol. ii. 237, &c.) 

Since the time of Larrey, several modifications of this 
method of treatment have been originated, and adopted in 
practice. 

M. Seutin, of Belgium, employs the following apparatus: 
it consists of strips of muslin arranged as in the bandage 
of Scultetus ; compresses of old linen, or of lint, and pieces 
of pasteboard softened in boiling water so as to be moulded 
to the limb. In applying this dressing, the fracture is re- 
duced, the limb restored, as nearly as possible, to its natural 
shape, and then covered with folds of the bandage of Scul- 
tetus, or of the simple roller ; upon this a layer of freshly 
prepared starch is applied by the hand, or by means of a 
brush ; then, having filled up the irregularities upon the 
surface with suitable compresses, the whole is enveloped 
in several layers of the bandage of Scultetus, or of the 
roller, thoroughly impregnated with the paste ; for the sake 
of cleanliness the last envelope should be applied dry. 

If there be a wound of the integuments, or if the fracture 
be compound, M. Seutin directs that an aperture, corre- 
sponding in situation with the wound, should be made in 
the bandage, or that the various dressings should not be 
applied upon this point. 

During the thirty-six or forty-eight hours required for 
the hardening of this case, the limb should be retained mo- 
tionless in some secure apparatus. 

At the expiration of from two to four days, M. Seutin 
directs that a slit should be made running longitudinally 
through the entire thickness of the envelope, so as to permit 
of the inspection of the limb ; if its condition be favourable, 
the case is closed again by applying an additional layer or 



130 TREATMENT OF FRACTURES. 

two of the starched bandage ; if the parts be too much com- 
pressed, throughout, a longitudinal section is made and a 
strip removed ; or if there be too much pressure upon any 
point merely, only portions of the case are cut away at 
corresponding points ; after which the apparatus is again 
secured as before. In this way, during the whole duration 
of the treatment, the limb should be inspected from time to 
time, and any difficulty remedied. 

As soon as the dressing has become perfectly solid, M. 
Seutin allows the patient — the lower extremity being the 
seat of fracture — to walk about upon crutches, the broken 
limb supported from contact with the ground by a sling 
attaching it to the neck. 

M. Velpeau advocates a plan somewhat different from 
M. Seutin's. The solidifying material which he employs 
consists of one hundred parts of dextrine beaten up with 
sixty parts of camphorated alcohol, to which is added forty 
parts of hot water, and the mixture is then shaken ; in 
two minutes the solution is ready for use. Having reduced 
the fracture, M. Velpeau applies a dry roller around the 
limb, and, after filling up the inequalities of the surface by 
compresses, follows it by a roller saturated with the above 
solution; sometimes he uses also pasteboard splints pro- 
perly softened and moulded to the limb, or, if these be not 
employed, he applies in succession a sufficient number of 
bandages, previously saturated, to afford firm support and 
protection. The limb is kept at rest until the dextrine 
shall have become dry. 

M. Velpeau makes use of this dressing immediately after 
the occurrence of the injury, notwithstanding the existence 
of swelling and inflammation, considering that the compres- 
sion which the bandage exercises upon the tissues, and the 
perfect immobility in which they are preserved, hasten 
very much the removal of this condition. He treats in 



TREATMENT OF FRACTURES. 131 

this way comminuted and compound fractures, in the latter 
cases leaving the wound uncovered by the bandage. Un- 
less some symptom occur to demand the removal of the 
dressing, M. Velpeau does not disturb it until the fracture 
has become consolidated. 

M. Langier employs strong paper instead of muslin, to 
envelope the limb. He cuts this paper into strips arranged 
as in the bandage of Scultetus, and having saturated them 
with the agglutinating mixture, covers the limb, including 
the foot, — if the leg be broken, — forming thus a firm and 
unyielding boot. This plan is resorted to immediately, and 
the limb inspected from time to time, as symptoms call for 
it, in which event the apparatus should be adjusted accord- 
ingly. 

The " Immovable Apparatus" may be very advan- 
tageously and safely used in the treatment of fractures, — 
particularly of the upper extremity, and of the leg, — after 
the injury has been treated in the ordinary way, for a suffi- 
cient time to have allowed of the cessation of liability to 
displacement of the fragments, in other words, when some 
degree of firmness has taken place. And it offers this 
great advantage over all other plans of treatment, that 
the individual upon whom it is applied may be permitted to 
walk freely with the aid of crutches, — exercising a reason- 
able caution, of course, — even with a broken leg. There 
are many persons who, from bad health, or from the press- 
ing requirements of business, will not bear the long con- 
finement to bed which the ordinary modes of treating a 
fracture of the lower extremity require : to such this plan 
is very happily adapted, suitable care being impressed upon 
them. 

If this method is resorted to from the first occurrence of 
the fracture, the limb should be carefully inspected daily, 
and at short intervals should be exposed, particularly until 



132 TREATMENT OF FRACTURES. 

it has become quite stiff, otherwise an irremediable degree 
of deformity may have occurred unsuspected by the sur- 
geon, or other accidents equally, or even more, serious. 

Another variety of the immovable apparatus has been 
recommended by M. Dieffenbach, of Berlin. It is made 
of plaster, poured when fluid upon the part which has been 
previously denuded of hair and smeared with oil. The 
case is made in several pieces, according to the shape of 
the limb, and when it has become solidified it forms a 
very unyielding envelope. It presents the same advan- 
tages and disadvantages as the methods already alluded to, 
and is much less frequently employed than the others. 
(For an account of the mode in which it is prepared and 
applied, the reader is referred to Vidal de Cassis, op. cit., 
vol. ii. p. 240, &c— Paris, 1846.) 

The second plan of treating fractures, to which allusion 
has been made, is that to which the term " Hyponarthecia" 
has been applied by M. Mayor, of Lausanne. This me- 
thod was first recommended by M. Sauter, but afterwards 
more fully developed by M. Mayor. The apparatus em- 
ployed consists of a piece of board, somewhat wider and 
longer than that division of the limb which may be the seat 
of the fracture, and covered with a cushion of about the same 
dimensions. The cushion is stuffed with oat-chaff, and is 
of sufficient thickness to allow at least one-third of the pos- 
terior part of the circumference of the limb to sink into it, 
and receive support from it. The fracture having been re- 
duced, the limb reposing upon the cushion, if there be but 
little tendency to displacement of the fragments, a wide 
cravat-shaped bandage merely is made to embrace both 
the splint and the limb, opposite to the seat of the injury; 
if this arrangement be found insufficient to retain the frag- 
ments in apposition, extending and counter-extending cravat 
bands are applied to the limb below and above the frac- 



TREATMENT OF FRACTURES. 133 

ture, and attached to corresponding extremities of the 
board. If the leg be broken, the extending band is made to 
act upon the foot and ankle and confined to a foot-board, 
while the counter-extension is made upon the leg just below 
the knee ; any disposition to lateral displacement can be 
remedied by acting upon the fragments by means of cra- 
vats passing to the sides of the board, one operating upon 
the upper and the other upon the lower fragment; or a 
single cravat may be so applied as to act directly upon the 
angle of displacement, and having its " point d'appui" upon 
the opposite side of the board. 

This apparatus may be stationary, or it may be sus- 
pended off the bed, — if the leg be broken, — by means of 
cords attached to the sides of the board, and allowed to 
vibrate gently in the air. M. Mayor has even permitted 
his patients to sit up in chairs, to the back of which a frame- 
work is attached arching over in front, with the apparatus 
suspended from it. If the arm be broken, the apparatus is 
suspended from the neck upon the chest, and the limb 
placed upon it and suitably confined by cravats. 

Under the head of special fractures, this apparatus will 
be illustrated. (See fig. 52.) 

The chief advantages which M. Mayor claims for this 
method of treatment are, that it leaves the fractured limb 
constantly open to inspection, that it is very simple in its 
arrangement and employment, and that it allows of a cer- 
tain degree and kind of movement of the limb as a whole, 
without permitting the fragments of the bone to become 
displaced; this last proposition, however, admits of so 
much doubt that, in most cases, we should dissuade from 
the employment of M. Mayor's method, considering it to 
be not sufficiently secure ; indeed the very fact that the 
apparatus, with the limb upon it, is allowed to execute, and 
is even arranged for, a degree of motion, though it be 

12 



134 TREATMENT OF FRACTURES. 

practised gently and with caution, renders some displace- 
ment almost certain. 

There are various accidents which are liable to occur, 
and many complications to be met with, in the treatment 
of fractures, which render necessary corresponding modi- 
fications of the methods ordinarily pursued. Such, for ex- 
ample, are excoriations, and sloughings of different parts 
of the surface ; wounds ; a tendency to particular varieties 
of displacement : these subjects will be more properly at- 
tended to in the consideration of special fractures, when 
the mode of obviating, or remedying, them will be pointed 
out. As, however, it is oftentimes necessary in cases of 
fracture to subdue inflammation, it will be convenient to 
state here that, the plan to be pursued in such circum- 
stances is to apply leeches upon the part, if required, and 
to leave the surface exposed, as much as shall be consis- 
tent with the proper security of the fragments, in order that 
cooling lotions shall be laid upon it, or other local antiphlo- 
gistic applications. 

Before proceeding to the special bandages and apparatus 
used in the treatment of this class of injuries, it will be pro- 
per to allude to two or three subjects of correlative interest 
and importance. 

When an individual suffers a fracture of the lower ex- 
tremity, — or meets with any injury which incapacitates 
him for walking,— the proper mode of removing him to his 
home, or to the hospital, is a serious concern. Generally, 
it is necessary, in such cases, to make use of any means of 
transportation which shall chance to present itself, as a 
window-shutter, or door, or a settee ; but every public in- 
stitution for the relief of the sick should have attached to it, 
as an important part of its apparatus, a vehicle contrived 
expressly for the purpose. This may be made like the 
ordinary hand-barrow, having its body about seven feet 
long and two and a half or three feet wide, provided with 



TREATMENT OF FRACTURES. 135 

a slatted or sacking-bottom, and with a mattrass and 
cushions, and supported off the ground upon legs, two feet, 
or more, in length : when used in carrying a patient, two 
men should be employed, one to sustain each extremity. 
The patient should be extended upon the mattrass, the in- 
jured part comfortably and securely reposing upon the 
cushions. If one of the extremities be fractured, or other- 
wise hurt, the limb should be so placed as that the painful 
action of the muscles shall be counteracted, as much as 
possible, by position, and attention should be directed, tem- 
porarily at least, to any pressing emergency, — for ex- 
ample, to the existence of hemorrhage, excessive pain, 
syncope, &c. 

The part which is the seat of the injury, should be ex- 
posed very gently by cutting off the clothes or other cover- 
ings which envelope it, rather than by drawing them away : 
the pantaloons, for instance, should be ripped along the 
outer seam, and the boots divided in the most convenient 
manner by a knife. In cleansing the surface, and in mak- 
ing the necessary examinations, delicacy of manipulation 
should be invariably studied, and the infliction of any un- 
necessary pain scrupulously avoided. In removing the 
patient from the litter, and in placing him upon the bed, 
the same care should be exercised, the injured part being 
supported by the surgeon himself. 

Not the least important desideratum in the treatment of 
those fractures, or other injuries, which require that the 
patient shall lie perfectly quiescent for a considerable length 
of time, is a proper bed, which is rarely to be met with. 
The fracture-bed in general use is an ordinary mattrass 
firmly and smoothly filled, and having a circular aperture 
cut through its centre, to correspond with a similar aper- 
ture in the sacking or floor of the bedstead. When the 
patient is about to have an evacuation, the cushion which 



136 



TREATMENT OF FRACTURES. 



covers the hole in the mattrass is removed, and a suitable 
vessel made to slide along a double groove, placed across 
the bottom of the bedstead, to receive the passage. The 
objections to this bed are that, the patient is obliged to raise 
himself, or to be raised, when the cushion is withdrawn 
and replaced, and that after the bed has been in use for a 
short time, it sinks very much in the middle, so as no 
longer to present a flat surface to support the body and 
hips ; both of these are serious objections and inconve- 
niences. They may be, in a great measure at least, ob- 
viated, by employing a bed constructed after the following 
method : the mattrass should be very firmly and evenly filled 
w 7 ith hair; it should be five or six inches in thickness, with the 
margins, or border, perpendicular, about seven feet long and 
from four to four and a half feet w 7 ide. An oblong section of 
about eight inches in width, and extending across the mid- 
dle from one side to the distance of a few T inches beyond 
the median line, should be removed and, after having been 
properly prepared, be arranged so as to be drawn backwards 
and forwards at pleasure upon the floor of the bedstead. 
The bottom of the bedstead should be made of board, and 
should be entire, with a movable section opposite that of the 
mattrass, corresponding with it in length and breadth, and 
so adapted as always to afford a perfectly firm support to 
it, which may be readily accomplished by allowing the slat 
to play upon a double groove. When an evacuation is to 
be received, one hand of the attendant should be placed 
underneath the hip of the patient, and the section of the 
bedstead and of the mattrass be withdrawn only so far as 
to allow the passage to take place freely, while the hip still 
reposes upon the edge of the section of the mattrass ; the 
vessel for receiving the evacuation may be supported in 
any convenient manner underneath the bedstead. Or an 
aperture of suitable size to permit of the evacuation, but not 



TREATMENT OF FRACTURES. 137 

unnecessarily large, may be cut in the centre of the mat- 
trass, and the portion which was removed adapted, by a 
hinge joint on its inferior surface, to close the aperture 
when the evacuation has been accomplished, being kept 
closed by a movable strip passing across the bedstead and 
constituting part of its floor. 

A very good substitute for the fracture-bed, particularly 
for children, — will be found in the clinical frame, such as 
is described in the Appendix of Cutler's treatise on ban- 
daging. It consists of a simple framework, of two longi- 
tudinal and two transverse bars attached at their extremi- 
ties, about seven feet long and a yard wide ; a single piece 
of canvass, with a circular aperture in its centre, is firmly 
stretched upon it, or several strips of webbing are nailed 
across it, intersecting each other in various directions, but 
leaving a sufficiently large vacant space in the middle. 
The frame thus prepared is habitually placed upon the 
mattrass, having been previously covered with a sheet in 
the centre of which a circular hole has been cut, and the 
patient reposes .upon it ; when he desires to have a passage, 
the frame is raised sufficiently off the bed, and supported 
in this position in any convenient and secure manner, while 
the evacuation is received in a proper vessel. The frame 
may be raised by two attendants, or by means of the tripod 
arrangement of Cutler, which consists of three strong bars 
united by a hinge-joint at their upper extremities, and 
having an iron ring, or hook secured to their point of union 
and presenting downwards : through this ring a long lever 
is passed, having attached to one end of it the cords by 
which the frame is suspended, while the force for elevating 
the latter is exerted upon the other extremity : when the 
frame is raised, the lever may be secured in position by 
cords attached to some fixed point. 

The apparatus of Jenks, of which a description and 

12* 



138 TREATMENT OF FRACTURES. 

a drawing are given in Gibson's Surgery, vol. i., is more 
complicated and very much more costly than the simple 
contrivance above described : it is however a much more 
perfect arrangement, and should be introduced into every 
hospital. But in private practice it is generally sufficient 
to trust to the fracture-bed for adults, and to the simple 
frame described for children who can be lifted from the 
bed bv mere muscular strength. 



CHAPTER II. 

BANDAGES AND DRESSINGS FOR FRACTURES OF THE 
BONES OF THE HEAD AND TRUNK. 

SECTION I. 

FOR FRACTURES OF THE BONES OF THE SKULL AND FACE. 

1. When, in fractures of the cranial bones there is dis- 
placement of the fragments, it is produced by the violence, 
whatever this may have been, which occasioned the solu- 
tion of continuity, and not, as in similar injuries of the 
long bones, by muscular action. Hence, after the dis- 
placement has been remedied, — if it be necessary, or ad- 
visable to attempt it, — bandages are only required for the 
purpose of protecting the injured parts from external irri- 
tation, and of retaining such dressings as may be applied ; 
they are, therefore, very simple, as for example, strips of 
adhesive plaster, the triangle of Mayor, the T bandage, or 
an ordinary night-cap, or finally, the recurrent bandage : — 
these have already been described. 

2. Generally, the same remarks may be extended to 
fractures of the facial bones, those of the nose for instance : 
the fragments having been restored as well as possible, to 
their natural positions, they need no bandages to preserve 
them " in situ;" the latter are serviceable only as retentive 
or protective means. 

3. In fractures of the inferior maxillary bone, however, 
the fragments are almost always displaced, and retained in 



140 FRACTURES OF THE SKULL AND FACE. 

their abnormal situations, by the direct action of the 
muscles which are connected with them, as the digastric, 
the hyoid, the pterygoid muscles, &c, &c. ; it becomes 
necessary, consequently, to employ some kind of bandage 
or apparatus which shall counteract the influence of these 
displacing agents. 

The bandages most frequently used for this purpose, and 
which will probably be found sufficient in all cases, — are 
the four-tailed of the chin, and those of Drs. Gibson and 
Barton of this city. 

1. The four-tailed bandage of the chin. 

Composition. — An oblong piece of stout pasteboard di- 
vided at each end to within an inch of the middle ; — a 
four-tailed bandage, prepared as directed in the section on 
bandages of the head ; — compresses. 

Application. — The pasteboard, previously softened by 
immersion in hot water and moulded to the form of the 
chin and jaw, (fig. 40,) is applied upon 
the seat of fracture ; then the middle 
portion of the bandage is placed upon 
the chin, over the splint ; the two supe- 
rior tails, a, a, fig. 20, are carried, one 
on each side, towards the nape of the 
neck, where they are crossed, and then 
conducted, one along each side of the 
head, obliquely upwards and forwards to the forehead, and 
pinned ; the lower tails, 6, b, are now carried upwards be- 
fore the ears, to the summit of the head, where they in 
turn are crossed, and then returned and confined beneath 
the chin. (Cutler, p. 70.) 

2. The bandage of Professor Gibson, and its application 
are thus described by the author himself: " The surgeon 
having carefully examined the injured parts, and replaced 
such teeth as may have been shaken or loosened, runs his 




FRACTURES OF THE SKULL AND FACE. 141 

finger along the margin of the jaw, models the parts to a 
proper shape, and closes the mouth firmly, making the 
lower teeth press fairly against the upper. Then a cotton 
or linen compress of moderate thickness, reaching from the 
angle of the jaw nearly to the chin, is placed beneath and 
held by an assistant, while the surgeon takes a roller, four 
or five yards long and an inch and a half wide, and passes 
it by several successive turns under the jaw, up along the 
sides of the face and over the head ; now changing the 
course of the bandage, he causes it to pass off at a right 
angle from the perpendicular cast, and to encircle the tem- 
ple, occiput, and forehead horizontally by several turns; 
finally, to render the whole more secure, several additional 
horizontal turns are made around the back of the neck, 
under the ear, along the base of the jaw, and over the point 
of the chin. To prevent the roller from slipping or chang- 
ing its position, a short strip may be secured by a pin to 
the horizontal turn that encircles the forehead, and passed 
backwards along the centre of the head as far as the neck, 
where it must be tacked to the lower horizontal turn,^ 
care being taken to insert pins at every point at which the 
roller has crossed. This simple method of securing a 
fractured jaw I have practised very successfully for several 
years." (Fig. 41.) 

3. Dr. J. R. Barton's bandage. 

Composition. — A roller five yards long and two inches 
wide ; suitable compresses. 

Application. — Place the initial extremity of the roller 
upon the occiput just below its protuberance, and conduct 
the cylinder obliquely over the centre of the left parietal 
bone to the top of the head ; thence descend across the 
right temple and the zygomatic arch, and pass beneath the 
chin to the left side of the face ; mount over the left zy- 
goma and temple to the summit of the cranium, and regain 



142 



FRACTURES OF THE SKULL AND FACE. 
Fig. 41. Fig. 42. 





the starting-point at the occiput by traversing obliquely the 
right parietal bone ; next wind around the base of the lower 
jaw on the left side to the chin, and thence return to the 
occiput along the right side of the maxilla ; repeat the same 
course, step by step, until the roller is spent, and then con- 
fine its terminal end. (Fig. 42.) 

These bandages are easily applied, and are very effica- 
cious; the pasteboard splint described in connexion with 
the first, will be found to be a very useful adjunct to the 
two latter. The bandage may be made to act upon any 
particular portion of the jaw, as required by the situation 
of the fracture, by modifying slightly the course of the 
roller in its successive turns, and by a proper position of 
the compresses ; a little reflection on the part of the dresser 
will enable him to adapt his means of treatment to the ends 
indicated in each case. 

Mr. Lonsdale invented a complicated apparatus for the 
treatment of a particular case of fracture at the symphysis 
of the lower jaw, in which much difficulty was experienced. 
He found it to answer perfectly in this instance, and in 
several other cases which occurred afterwards. The ends 
which he had in view, and which he gained by this appa- 



FRACTURES OF THE BONES OF THE TRUNK. 143 

ratus, were, " to apply all the force and pressure to the 
lower jaw alone ; to fix the two portions of bone between 
two parallel forces, by applying one on the teeth, and the 
other under the base of the jaw ; lastly, to keep the two 
portions of bone on the same vertical plane, by fixing them 
in a grooved plate placed along the teeth." For the de- 
scription and illustration of Mr. Lonsdale's apparatus, the 
reader is referred to this gentleman's " Practical Treatise 
on Fractures," p. 234, et seq. ; or to Mr. Cutler's book, p. 
71, et seq. 

If the fracture be compound, or in a simple fracture 
complicated with a wound of the cheek, or chin, the folds 
of the bandage must be so arranged as not to press with 
too much force directly upon the wound, and to allow of 
the application of suitable dressings, of which the first ob- 
ject is to promote immediate closure of the wound. 



SECTION II. 

BANDAGES FOR FRACTURES OF THE BONES OF THE TRUNK. 

1. For fractures of the vertebra. 

The bones of the spinal column are very much screened 
and protected from fracture by their peculiar shape and 
situation ; hence they are rarely broken. When they are 
thus injured, it is most frequently the spinous process which 
suffers, as being the most exposed and, from its form and 
structure, the most readily broken. But very little dis- 
placement follows when it is fractured, since it is imbedded 
in muscles and ligaments, and acted upon with equal force 
from both sides. A bandage is not, therefore, really needed 
in cases of this kind ; it is very proper, however, to make 
use of the roller, as exhibited in fig. 27, or of the laced 



144 FRACTURES OP THE BONES OF THE TRUNK. 

bandage of the chest, already described, with compresses 
placed upon the spinous process, in order to insure perfect 
apposition of the fragments and to prevent injury from the 
movements of the patient in bed. The injury done to the 
spinal medulla is generally such as to demand more atten- 
tion on the part of the surgeon, than the mere fracture. 
The condition of the bladder especially will require watch- 
fulness, retention of urine being a very common accompa- 
niment of the accident, and demanding the introduction of 
the catheter at least twice daily. Sloughing of the integu- 
ments, wherever pressure falls, is also a troublesome com- 
plication, and one which should be prevented, if possible, 
by frictions of such parts and by the proper adjustment of 
pillows. 

2. For fractures of the ribs and sternum. 

A little reflection upon the shape and connexions of these 
bones will show that there cannot, as a general rule, be 
much displacement of their fragments when they are 
broken. The ribs are attached to each other both above 
and below, and throughout their entire length, by the inter- 
costal muscles ; they are strongly bound to the vertebrae, 
and connected to the sternum in front by a very elastic 
tissue ; while the sternum is itself securely united to the 
clavicles, and retained " in relief," as it were, by the 
numerous costal arches which subtend it on each side. 
Thus the whole, and each part, are so elastic that they re- 
gain their original shape, when this has been altered in case 
of fracture, unless the fragments are driven into the cavity 
of the chest by great violence. 

The general indication of treatment in fractures of the 
ribs and sternum is to prevent, as much as practicable, the 
play of the thoracic respiratory muscles, devolving the 
performance of the mechanical acts of respiration upon 
the diaphragm, thereby preserving the broken bones in a 



FRACTURES OF THE BONES OF THE TRUNK. 145 

state of comparative repose. To accomplish this, com- 
presses and a bandage of some sort are necessary. The 
laced or buckled bandage of the chest will answer very 
well in many cases, but generally the roller is to be pre- 
ferred. Its application should be commenced from below, 
the patient having previously made a forcible expiration ; 
the roller should ascend to the axilla bv circular turns, 
made with considerable tightness, and then pass obliquely 
upwards and outw 7 ards from the axilla to the root of the 
neck on the opposite side, and down in front of the chest, 
crossing the circular folds of the bandage which it serves to 
secure by means of pins inserted at intervals. The roller 
for this bandage should be about eight yards long and three 
inches wide. 

The proper disposition of the compresses is a matter of 
much importance in the treatment of these fractures. If a 
rib has been broken by force acting upon its anterior por- 
tion, the solution of continuity has occurred probably near 
the angle, where the anterior and posterior curves meet ; 
the first effect of the violence has been to increase the bend 
of the rib at this region, and finally to rupture its fibres ; of 
course there will be an angular displacement externally, 
and the compress should be applied either directly over the 
fracture, or one should be placed a little anteriorly and 
another just posteriorly to it. But when the force impinges 
upon the angle or side of the rib, if there be any displace- 
ment appreciable, it is probably towards the cavity of the 
chest, and the compresses should be so placed as to restore 
if possible, the natural curve of the bone, and thus to throw 
the fragments outwards. To effect this object, apply one 
compress upon the rib near its junction with its cartilage, 
and another near its angle, as far posteriorly as may be ; 
or, as Mr. Lonsdale advises, a broad lath or piece of paste- 
board, may be laid upon the side of the chest and confined 

13 



146 FRACTURES OF THE BONES OF THE TRUNK. 

by a roller, being made to press with especial force upon 
points remote from the seat of fracture. 

If the sternum has been broken, and there be depression 
of one of the fragments, a compress should be laid upon 
the portion which is not depressed, near the line of fracture, 
and another upon the depressed portion of the bone at a 
point remote from the rupture, so that, when the roller is 
made to act forcibly upon the two, the first fragment will 
be depressed and the other elevated, at the broken margin. 

The bandage should be worn four or five weeks. 

3. For fractures of the pelvic bones. These bones are 
very rarely broken, and they are so enveloped, individually 
and collectively, in muscular and ligamentous expansions 
covering their whole surfaces, that in the event of fracture 
there can be but slight displacement, unless when the frag- 
ments are violently forced inwards. 

The indication for the treatment is, of course, to keep 
the fragments at rest. To accomplish this a broad roller 
should be passed firmly around the upper part of the thighs 
and the pelvis, and compresses judiciously applied to enable 
the bandage to act upon particular points, as may be re- 
quired. Perfect quiescence should be enjoined upon the 
patient for a length of time, — from two to two and a half 
months. The state of the bladder must be carefully 
attended to. 

In cases of compound fracture of the bones of the head 
and trunk, the dressings must be so applied as not to press 
with too much force upon parts surrounding the wound, 
otherwise sloughing of the integuments may ensue. The 
bandage should cover the wound very lightly, in order 
that suitable applications may be made to it ; it is better 
indeed that the bandage for the fracture itself shall leave 
the wound exposed, and that an additional retentive band 
be employed for such dressings as may be called for. 



CHAPTER III. 

ON THE APPARATUS AND DRESSINGS FOR FRACTURES 
OF THE BONES OF THE SHOULDER. 

SECTION I. 
FOR FRACTURES OF THE CLAVICLE. 

The slender proportions and exposed situation of this 
bone render it very liable to be broken ; and in the great 
majority of instances a considerable degree of displace- 
ment accompanies the fracture ; the exceptional cases are 
those in which the solution of continuity has occurred at 
the acromial extremity of the bone, where the surface is 
broad and covered with ligamentous expansions. But 
when, as generally happens, the fracture has involved the 
more central portions of the clavicle, an angular deformity 
is produced, presenting anteriorly, the scapular fragment 
being dragged downwards by the weight of the arm, and 
drawn towards the median line of the chest, in front, by 
the action of the pectoral muscles ; the sternal fragment is 
but little deviated from its natural position, being held in 
place by the combined but counteracting forces of the 
sterno-clavicular and costo-clavicular ligaments, and of the 
sterno-cleido-mastoid muscle; the prominence seen and 
felt at the point of fracture is due, in most cases to the 
sternal fragment, the scapular portion being drawn rather 
below and behind the other ; sometimes, however, the sca- 
pular fragment projects in advance of the sternal. The 



148 FRACTURES OF THE CLAVICLE. 

fracture is usually oblique and simple ; comminuted and 
compound fractures occur, however, at times. 

The indication to be pursued in the treatment of this 
injury is, of course, to reverse the line of displacement of 
the scapular segment of the bone; viz., to force the shoul- 
der, and with it the fragment of the clavicle which is at- 
tached to it, upwards, outwards, and backwards; and hav- 
ing thus restored the natural form of the clavicle, to retain 
the parts in this position until consolidation of the fracture 
shall have taken place. The first, or the reduction, is not 
difficult; the last demands constant care from the surgeon, 
and a well- contrived apparatus. In regard to this, M. 
Vidal (de Cassis) says — " fracture of the clavicle is almost 
always followed by deformity;" and he adds very truly, 
" but this deformity is not attended with much inconveni- 
ence, and does not seriously impair the movements of the 
limb." In females particularly, however, a deformity in 
so exposed a situation as this, must be unpleasant, and every 
endeavour should be made to prevent its occurrence. 

It is interesting to trace the progressive steps which have 
been made in the treatment of this injury. " Hippocrates 
considered it necessary merely to draw the shoulder out- 
wards and backwards. With this view he directed the 
patient to lie upon some prominent body, the back only 
being supported, while the shoulders were forced back- 
wards and outwards by their simple weight. Paulus CEgi- 
neta, in addition to this, placed a pad in the axilla. Guy 
de Chauliac endeavoured to fulfil the same indication by 
means of a bandage applied around the shoulders in the 
form of the figure 8, which plan was generally adopted, 
and of which many surgeons recommended modifications 
without, however, increasing its efficacy." (See Vidal de 
Cassis, op. cit , vol. ii. p. 291, et seq.) Thus from time to 
time until the present day, many varieties of apparatus, 



FRACTURES OF THE CLAVICLE. 149 

some of them very complicated, possessing different degrees 
of excellence, have been contrived for the treatment of 
fractures of the clavicle. It was reserved, however, for one 
of our own countrymen, a surgeon of this city, Dr. George 
Fox, — to invent, in the year 1828, an apparatus which ad- 
mirably fulfils every indication, is very simple in its con- 
struction and application, is more comfortably borne, per- 
haps, than any other, and yet leaves the injured clavicle 
freely and constantly exposed to the view of the surgeon, 
and for the application of topical remedies, if required. 

The apparatus of Dr. Fox consists of a firmly stuffed pad 
of a wedge shape, and about half as long as the humerus, 
having a band attached to each extremity of its upper or 
thickest margin ; a sling to suspend the elbow and forearm, 
made of strong muslin, with a cord attached to the humeral 
extremity, and another to each end of the carpal portion ; 
and a ring made of muslin stuffed with cotton to encircle 
the sound shoulder, and serve as means of acting upon and 
securing the sling. The apparatus is applied thus: — Pass 
the arm of the uninjured side through the ring, so that the 
latter may surround the shoulder ; press the thick end of 
the pad firmly against the summit of the axilla of the affected 
side, and carry the bands which are attached to it one in 
front of and the other behind the corresponding shoulder, 
to cross upon the root of the neck and traverse the chest 
obliquely, before and behind, and to be tied to the ring ; then 
having fixed the elbow and the forearm corresponding with 
the fractured clavicle in the sling, conduct its posterior cord 
behind the thorax, and the two anterior cords in front of 
it, and secure them to the ring. The shoulder can be 
operated upon very powerfully by means of these cords; 
it can be thrown upwards, or backwards and outwards, to 
any required degree, and one of these motions can be im- 
pressed upon it at pleasure, until the surgeon shall be satis- 
fied with the position of the fragments. 

!3* 



150 



75.ACTV7.Z5 :t 7ZZ :1aVI;1Z. 



Soft pad 3 of cotton should be interposed between the 
surface and the apparatus at different points ; and,, from 
time to time, when the surgeon re-arranges the dressings, 
he should endeavour to make the pressure bear upon parts 
of the surface which have not previously, or recently, been 
acted upon. The point of the elbow will require protection 
in this way ; frequently it is well to make a circular aper- 
ture in the sling and, having covered it with a flattened 
mass of cotton, to allow the point of the elbow to sink 
into it. 

If the fracture is comminuted, a compress may be placed 
over the fragments, to assist in the securing of perfect 
?rz : ?:'.; z. 

Fractures of the clavicle, treated by this apparatus, are 
daily dismissed from the Pennsylvania Hospital, and by 
surgeons in private practice, cured without perceptible de- 
formity ; and no one who has employed it will be disposed 
to use any other as a substitute. 

The annexed drawing exhibits this dressing as applied. 

(Fig. 43. | A mere in- 
spection of it will show 
the advantages of this 
apparatus over all 
others, in the complete 
performance of the re- 
quisite evolutions of the 
shoulder, the exposure 
of the injured parts, 
its lightness, and the 
avoidance of impedi- 
ment to respiration, and 
of pressure upon the 
mammary glands when 
it is applied to females ; 
in each of these parti- 



Fir. -:•: 




FRACTURES OF THE CLAVICLE. 



151 



culars the complicated bandage of Dessault, which is still 
used by some surgeons, is open to serious objection ; the 
same remark is likewise applicable to the plan of treatment 
recommended and illustrated by M. Velpeau (op. cit., vol. 
i. p. 229) ; indeed this must be less efficacious than the 
other, since it merely confines, by means of a roller, the 
hand corresponding with the broken clavicle upon the 
sound shoulder, no pad being placed in the axilla to force 
the scapular fragment outwards. (See fig. 45.) 

As a temporary bandage, to be employed during the 
short time necessary for the preparation of Fox's appara- 
tus, if the surgeon have not one already made, that recom- 
mended by Mr. Lonsdale may be used. A pad, resembling 
in shape that already described, is to be secured in the 
axilla by means of a roller. 
" The elbow is next to be Fi ^ 44> 

brought before the chest as 
far as possible, and to be 
held there, while a few turns 
of the roller are passed 
around to confine it to the 
thorax ; a sling is then to 
be applied, which must be 
made very short, so as to 
prevent the elbow from fall- 
ing from the position into 
which it has been brought, 
for upon this depends the whole action of the humerus on 
the scapular end of the clavicle." (Lonsdale, op. cit., pp. 
212,213.) (Fig. 44.) 

A bandage very similar to this was described by Dr. 
Brown, of New York, in the Philadelphia Medical Re- 
corder of 1821. It requires that a pad of a wedge shape 
shall be confined in the axilla by means of a roller, which 




152 FRACTURES OF THE CLAVICLE. 

also fixes the forearm, previously flexed at an acute angle 
upon the breast, leaving the wrist and hand to be supported 
by a sling. This bandage is described in detail and illus- 
trated by a drawing in the Medical Recorder, as above 
mentioned. 

Many other plans of treatment have been proposed and 
resorted to, but the apparatus of Fox will be found of itself 
sufficient for all cases which may occur. Latterly, an en- 
tirely novel method has been instituted in France by M. 
Guillou; this gentleman reported it to the Academy of Sci- 
ences of Paris, and the description of his mode of treat- 
ment w 7 as published in full in " L'Abeille Medicale," for 
October, 1847 ; the following summary is taken from that 
journal : 

The apparatus consists of five pieces, — 1st, of a sling 
made of a handkerchief of proper length ; 2d, of a cravat 
folded in the middle ; 3d, of a body-bandage formed of a 
towel ; 4th, of a square cushion of linen, thicker in the 
middle than along the margins ; 5th, of a pad for the ax- 
illa, having a band of about a foot and a half long attached 
to its base on each side. 

In the adjustment of the apparatus, the pad is placed in 
the axilla of the injured side, and secured in this position 
by crossing its bands upon the sound shoulder ; the fore- 
arm is then thrown behind the back and supported by the 
sling, which is passed around the neck, and made longer 
or shorter, according to the degree of force which it may 
be necessary to exert upon the external fragment of the 
clavicle, since the more the forearm is raised, the more 
the external fragment will be thrown outwards, backwards, 
and upwards ; in order to confine the arm securely in this 
position, the body-bandage is applied, to compress the lower 
part of the humerus against the thorax, while the cravat 
band acts in a similar manner upon the upper portion of the 



FRACTURES OF THE SCAPULA. 153 

arm, being wrapped around this part of the humerus, and 
fastened upon the sound shoulder ; to increase the power of 
the cravat, the square cushion is inserted between it and 
the back, and the cravat and the body-bandage are pinned 
to it. 

The author has not had an opportunity of testing the effi- 
cacy of this apparatus, but it would seem to be capable of 
fulfilling all the indications, leaving the seat of fracture 
completely exposed to view. The cravat band may proba- 
bly be dispensed with, without lessening the value of the 
apparatus. 

M. Guillou has employed this method of treatment for 
some years, and prefers it to all others. 

The duration of treatment of cases of simple fracture of 
the clavicle may be stated at six or eight weeks. 



SECTION II. 

FOR FRACTURES OF THE SCAPULA. 

Viewing merely the prominent situation of the scapula, 
and its rather delicate physical conformation, one would 
fancy that it was particularly subject to breakage ; but this 
is not really the case. It reposes upon a soft and yielding 
bed of muscular tissue, and is covered by the same sort of 
structure, so that any force which acts upon the scapular 
region is deprived of a large part of its capacity to injure, 
before its influence has extended to the bone itself. Even 
its projecting processes, little adapted as they are in them- 
selves to resist violence, are sheltered and protected in the 
same way. 

The parts of the scapula which are most often broken 
are, in the order of frequency, the acromion process; the 



154 



FRACTURES OF THE SCAPULA. 



inferior angle of the bone ; the body ; the coracoid process, 
and finally the neck. 

1. Of the bodv and inferior alible. 

When the body of the scapula is fractured either ob- 
liquely or transversely, there cannot be much separation 
or displacement of the fragments, since its whole surface, 
both in front and posteriorly, is covered by an expansion 
of muscular fibres, having an attachment around the mar- 
gin of the bone. The indication to be kept in view, there- 
fore, in the treatment of this accident, is merely to main- 
tain the fragments at rest, by preventing the action of the 
muscles which operate upon them directly and indirectly. 
This object is readily and completely attained, by applying 
over the body of the scapula a broad compress, and secur- 
ing it in this situation, by passing a wide roller around the 
chest ; the arm should be kept at rest in the flexed position, 
supported in a sling, and confined upon the breast. 

When a fracture separates the inferior angle from its 
connexion with the body of the scapula, the former is more 
or less drawn away from the latter by the action of the 
teres major muscle. Hence, in the treatment of this frac- 
ture, the arm should be carried backwards towards the 
scapula, in order to relax this muscle, and confined in this 
position by means of a broad roller, which shall likewise 
press upon the body of the bone and its inferior angle, — 
the fragments having been put in apposition, — by the inter- 
vention of compresses placed directly upon these parts. 
The forearm should be supported by a sling. 

2. Of the coracoid process. 

This portion of the scapula is placed very much out of 
the reach of injury, yet it is occasionally broken. When 
fractured, a certain amount of displacement will probably 
occur as a result of the action of the three muscles attached 
to it, viz. the pectoralis minor, the coraco-brachialis, and 



FRACTURES OF THE SCAFULA. 155 

the short head of the biceps, whose combined agency will 
drag the fragment downwards and somewhat inwards, to- 
wards the point of origin of the smaller pectoral muscle. 

To readjust the fragments, the above-named muscles 
must be relaxed, and some small compression made over 
the broken process. The forearm should be flexed to an 
acute angle and supported upon the breast, the hand of the 
injured side resting upon the sound shoulder, while a gra- 
duated compress is confined over the natural situation of 
the coracoid process by means of the spica bandage (fig. 
36). Or the bandage which M. Velpeau recommends for 
the treatment of fractures of the clavicle (op. cit., p. 229), 
will fulfil the same indications very well ; thus : select a 
roller from ten to twelve yards long and two and a half 
inches wide, and apply its initial extremity to the axilla of 
the sound side; then conduct the cylinder obliquely up- 
wards over the back to the affected shoulder, place the 
hand of this side upon the opposite shoulder, the forearm 
reposing upon the chest, and continue the roller over the 
clavicle of the injured side, across the upper part of the 
arm to the outside of the same, and so under the arm, the 
elbow and the forearm to the axilla of the sound side; from 
this point, repeat the same course until several turns have 
been made in doloires opening towards the point of the 
shoulder. Having reached the axilla after the fourth or 
fifth fold, continue the roller in circular sweeps passing 
horizontally around the back, the axilla of the injured side, 
the arm, elbow and forearm, and thus alternate the oblique 
and horizontal turns until the roller is exhausted. In order 
to make the folds secure, insert pins at the different points 
of crossing, or cover the whole with the starch or dextrine 
solution. A graduated compress applied upon the coracoid 
process, before crossing it with the roller, will adapt this 



156 



FRACTURES OF THE SCAPULA. 



bandage more perfectly to this particular fracture. (Fig. 
45.) 

Fig. 45. 




3. Of the acromion process and the neck of the scapula. 

When the neck of the bone is separated from the body, 
it is drawn downwards by the weight of the arm, and the 
course of treatment is at once rendered manifest, viz., to 
apply such a dressing as shall restore the bone to its na- 
tural situation and preserve its apposition with the main 
fragment. A pad should be placed in the axilla against 
the head of the humerus and firmly supported, while the 
shoulder is raised and the arm maintained in repose upon 
the breast, with the forearm flexed. Fox's apparatus for 



FRACTURES OF THE SCAPULA. 



157 



fractures of the clavicle fulfils all the indications very per- 
fectly. (See fracture of the clavicle.) 

When the acromion process is broken, the weight of the 
arm, as in the other case, draws the fragment from its 
natural position, and the same kind of treatment is indi- 
cated, with the addition of a certain degree of compress- 
sion upon the process itself. The apparatus of Dr. Fox 
is applicable to this injury, also — with a figure-8 bandage 
applied to act upon a compress placed upon the acromion 
process (see crossed bandage of shoulder and axilla) ; or 
the mode of dressing recommended by Mr. Lonsdale will 
fulfil the indications very elegantly. The process may be 
steadied by the spica bandage, which is to be applied over 
the shoulder and then under the axilla of the affected side, 
&c. &c, until the roller is nearly exhausted. The last 
part of the bandage may be made to cross the shoulder, to 
descend in front and pass under the elbow and lower part 
of the forearm, by which means any degree of pressure 
can be made upwards with the head of the humerus, by 
simply shortening that 
portion of the roller 
which passes under the 
elbow. The wood-cut 
(fig. 46) represents this 
bandage applied. (Lons- 
dale, p. 202, 3.) It will 
be seen at once that, by 
regulating the length of 
the sling on which the 
elbow reposes, and al- 
lowing the wrist and 
hand to droop more, or \ \ 
less, as may be required 
in each particular case, 

14 




158 FRACTURES OF THE SCAPULA. 

the degree of pressure upwards against the acromion pro- 
cess may be much modified. This bandage of Mr. Lons- 
dale is open to the objection, that it does not sufficiently 
confine the arm. 

The bandage of Velpeau, above described, will also an- 
swer very well for the treatment of this fracture. (Fig. 45.) 

After fractures of the scapula, generally, the parts should 
be kept at rest in a secure apparatus for six or eight weeks, 
and when the neck of the bone is detached from the body, 
a longer time is required to complete the union : Sir A. 
Cooper fixes it at from ten to twelve weeks. But as soon 
as the fragments have become so far united, as that there 
is no perceptible motion between them, upon careful and 
gentle handling, passive motion should be resorted to: this 
is particularly important in fracture of the neck of the sca- 
pula, for if the shoulder joint is allowed to remain perfectly 
motionless during the ten or twelve weeks which are requi- 
site for entire solidification of the fracture, the head of the 
humerus will be found to have become so firmly fixed in 
its socket, that another series of weeks will be required to 
restore to the joint its ease of motion. 

In compound fractures of the scapula and clavicle, an 
object of primary importance is, as in all other compound 
fractures, to convert the injury as speedily as possible into 
a case of simple fracture, by inducing closure of the wound 
by the first intention. The mode of effecting this is the 
same as in other similar injuries: by approximating the 
edges of the wound, and retaining them in contact by ad- 
hesive plaster. If the surgeon fails of accomplishing this 
purpose, and suppuration ensues, the poultice, or the water- 
dressing, must be substituted. 



CHAPTER IV. 

ON THE APPARATUS AND DRESSINGS FOR FRACTURES 
OF THE BONES OF THE UPPER EXTREMITY. 

SECTION I. 
FOR FRACTURES OF THE HUMERUS. 

It is in fractures of the long bones of the extremities, 
that displacements are most frequent and most varied in 
direction ; for these bones are acted upon at different points 
of their surface by numerous muscles, having contractile 
fibres varying in their lengths and in their directions of 
contraction. Hence, in a measure, the great numbers of 
apparatus which have been contrived for the treatment of 
these injuries. 

The humerus may be broken in its shaft, or at the con- 
dyloid, or scapular extremity ; the first is the most frequent 
seat of fracture. 

1. Fracture at the shaft of the bone may occur either 
above, or below, the line of insertion of the deltoid muscle ; 
in either case, there will be displacement of the portions of 
the bone, excepting in rare instances when the fracture is 
strictly transverse, and has been caused by a force insuffi- 
cient to throw the lower fragment from the axis of the 
upper ; and even if the arm be not shortened, it will pro- 
bably be somewhat curved by the action of the muscles, 



160 FRACTURES OF THE HUMERUS. 

which operate from above the fracture upon the lower 
fragment. 

When the fibres of the bone have been ruptured above 
the insertion of the deltoid, the upper segment will be 
drawn inwards towards the chest, by the action of the pec- 
toralis major, chiefly, while the lower fragment will be 
drawn upwards and outwards by the combined action of 
the deltoid, and the triceps and biceps muscles. 

If the fracture has occurred below the attachment of the 
deltoid, this muscle will raise the upper fragment outwards, 
while the lower portion will be drawn a little upwards, and 
inwards also with reference to the assumed position of the 
upper fragment, by the contraction of the muscles which 
pass from the scapula to the lower part of the arm and the 
elbow. 

Whether the shaft of the bone has been broken above, 
or below, the point under consideration, the indications of 
treatment will be the same, viz. : to restore the limb to its 
proper length and axis, if these have been altered, and to 
keep the parts at rest. This object will be best accom- 
plished by the following plan, which is adapted to both of 
the supposed cases : — Envelope the arm, from the fingers 
to the axilla, by a roller applied so as to make uniform and 
moderate pressure upon the muscles ; then, the arm being 
carefully supported by an assistant, take four splints made 
of thin wood, — (the sides of a cigar-box will answer per- 
fectly well,) — and evenly padded with cotton, and apply 
them separately in front, and at the sides of, and behind the 
arm, and secure them in these situations by a roller. The 
splint for the anterior face of the arm should extend from 
the head of the bone to just above the bend of the elbow ; 
the others from the same point to the extremity of the hu- 
merus, the projections of the condyles being carefully pro- 
tected from too much pressure. After the splints have been 



FRACTURES OF THE HUMERUS. 161 

bandaged to the arm, this should be brought a little for- 
wards, so that the forearm resting in a sling, may be sup- 
ported on the front of the chest, in the flexed position. In 
order to give greater security to the arm, a few circular 
turns of the roller should confine it to the chest. 

If, from any cause, it be desirable to dispense with the 
inner splint, the fracture may be treated equally well, by 
securing a wedge-shaped pad in the axilla, the thick end 
downwards, so as to present a perpendicular surface from 
the glenoid cavity to the extremity of the humerus, upon 
which the latter may restr then, having applied the roller, 
and the three other splints, as directed above, place the 
inner surface of the arm against the pad, and bandage it to 
the chest by circular sweeps of the roller: the forearm 
should be supported in a sling, as above directed. 

Another modification of the same plan consists in sub- 
stituting for the short splint, which is applied upon the 
inner aspect, or on the front of the arm, a rectangular 
splint, made to extend all along the inner or the anterior 
face of the limb, from the head of the humerus to the ends 
of the fingers. Thus, all motion of the forearm will be 
prevented. 

There is rarely much disposition to great shortening of 
the arm, in fracture of the shaft of the humerus; so that, 
in the vast majority of cases of this accident, the lateral 
pressure effected in the manner just described, is amply 
sufficient to retain the fragments in apposition. Mr. Lons- 
dale, however, has met with several cases in which he 
found it necessary to keep up permanent extension and 
counter-extension ; and, to accomplish this object, he in- 
vented a splint which he thus describes : — " It consists of a 
thin bar of iron, about an inch and a half wide, and long 
enough to extend from the axilla to the elbow, — marked B 

14* 



163 



FJ.ACTTF.E5 OJ JET EVMEF.T5. 



47 




in the wood-cut (See fig. 47.) The lower 
end of the bar curves upwards underneath 
the elbow, so as to allow of this part of the 
limb fitting into it, at C. This carve ter- 
minates in a hook, E, for the attachment 
of a bandage ; and on the splint opposite 
to this hook is a small bar. placed across 
the perpendicular, also for the attachment 
of a bandage. To the upper extremity of 
the splint a crutch is adapted, A, which 
fits underneath the axilla, and is movable 
up and down, being confined at pleasure 
by means of a small screw, placed at the 
side of the vertical bar." In applying it, 
the crutch-like extremity is secured in the 
axilla, the upper part of the arm fitting into it, and the 
elbow is confined in the inferior curve by means of a ban- 
dage passing around the limb at the elbow, and having at- 
tachments to the splint at the hook, and at the transverse 
bar, as already indicated. The whole arm should be en- 
veloped by a roller, and one or two lath splints applied on 
the exterior, or anterior, surface of the limb; the fore- 
arm should be supported in a sling. (Lonsdale, or. cit. 
;-. 1T3. vSc:. 

Il is very conceivable that a splint of this kind would be 
of much use in cases of compound fracture of the humerus, 
where the limb cannot be wrapped in splints and bandages 
in the usual manner, and where some degree of compres- 
sion and support is required to keep the fragments, in any 
measure, in place. If employed in such cases, the straight 
splints and the enveloping of the limb should be omitted ; 
but the arm should be lightly secured to the splint at the 
axilla, and also at the elbow, while another roller, or a 



FRACTURES OF THE HUMERUS. 163 

bandage of Scultetus, shall at once serve to retain the frag- 
ments in tolerable apposition, to confine upon the seat of 
fracture any proper application, and to support the whole 
against the side of the splint. A little ingenuity on the 
part of the surgeon will enable him to form a splint of 
wood, after the pattern of Mr. Lonsdale, which will an- 
swer the purpose equally well. But compound fractures 
of the humerus may be treated very well, in most instances, 
by placing the arm in a curved splint made of sheet tin, 
or of pasteboard, moulded to an arm of somewhat larger 
diameter than that of the patient, and well padded; the 
limb should be secured to the splint, above and below the 
seat of fracture, by means of a roller carefully applied, and 
leaving the wound exposed ; then, by a. bandage of Scul- 
tetus, a suitable dressing should be retained upon the 
wound, and this part of the arm pressed gently against the 
splint : the forearm must be supported as usual. 

After a certain time, when the fracture, whether it may 
have been simple or compound, has become tolerably firm, 
two curved splints, made of pasteboard, may be conve- 
niently substituted for the ordinary lath splints ; or the im- 
movable apparatus may be used. The usual time required 
to insure the consolidation of this form of fracture is about 
six weeks. 

2. Fractures of the upper extremity of the humerus. 

The humerus may be broken either at its surgical neck, 
that portion of the bone, namely, which is included between 
the margin of the articular head and the point of the inser- 
tion of the pectoralis major muscle, or at its anatomical 
neck, a narrow rim of bone separating the curved head 
from the tubercles. Fracture at the surgical neck is much 
the most common. 

When the bone is broken at the anatomical neck, there 
is often little or no displacement, the fractured surfaces 



164 FRACTURES OF THE HUMERUS. 

being so broad at this point. But there is generally some 
derangement of the axis of the limb, the lower fragment 
being drawn inwards by the pectoralis major, and upwards 
by the muscles which pass from the scapula to the lower 
part of the arm. 

The displacement is greater when the fracture occurs at 
the surgical neck, for the upper fragment will be rotated 
outwards by the supra and infra-spinatus muscles, while 
the lower portion is acted upon as before mentioned. 

In both cases the same indication is to be fulfilled, and 
it will be readily accomplished by confining a pad in the 
axilla, with the thick end downwards, so as to present a 
plane, perpendicular surface to the shaft of the limb ; then 
apply a roller from the fingers up to the head of the arm, 
and having reduced the fragments to apposition, place a 
compress over the seat of fracture on the outer face of the 
arm, and upon this a curved pasteboard splint extending 
from the acromion process to the outer condyle ; support 
the forearm in a sling, and confine the arm to the side of 
the chest by circular folds of a roller passing from the 
elbow to the shoulder. Or an angular splint may also be 
bandaged to the inner face of the arm and forearm, the 
hand being semi-pronated, — and the pad used as above. 

The limb should be kept perfectly at rest for six or eight 
weeks, excepting that after the fracture has become suffi- 
ciently firm, passive motion should be gently made, every 
day or two as the bandages are freshly applied. 

3. Fractures of the condyloid extremity of the humerus. 

The shaft of the bone may be broken just above the con- 
dyles, as is represented in the annexed drawing (fig. 48), 
taken from Sir A. Cooper's Treatise on Dislocations and 
Fractures, p. 401, American edition; or the fracture may 
implicate the condyles themselves, " extending in three di- 
rections : First, the extremity only of either condyle may 



FRACTURES OF THE HUMERUS. 

Fig. 48. 



165 




be broken off, as represented at A, in the wood-cut (see fig. 
49). Secondly, the fracture may include a larger portion 
of one condyle only, but extend directly into the joint, as 
at B. Thirdly, both the condyles may be severed from 
each other, and from the shaft of the bone as well, as 
shown at C." (Lonsdale, p. 181.) 

Fig. 49. 






When the solution of continuity has involved the shaft of 
the bone, immediately above the condyles, the lower frag- 
ment will be drawn upwards and behind the humerus by 
the contraction of the triceps muscle, dragging with it, of 
course, the forearm, as represented in figure 48, — or it may 
be drawn up on the front of the arm, depending, in a great 
measure, upon the direction of the force which caused the 
fracture. The same sort of displacement may ensue when 
the whole of the internal condyle is split off, as shown at 
B, fig. 49, since the ulna will be acted upon by the same 
muscles as in the other case ; but there need not be this 



166 FRACTURES OF THE HUMERUS. 

separation of the fragments, unless the violence has been 
sufficient to rupture the external lateral and the capsular 
ligaments. So also when the external condyle alone is 
severed from its bony connexions, the ligaments may still 
retain it in place, if they have escaped rupture ; and dis- 
placement is still less necessary if the point merely of the 
internal condyle be broken off, as at A, fig. 49. But when, 
as at C, the condyles are not only separated from each 
other but from the shaft of the bone likewise, shortening of 
the arm is an almost certain result, from the operation of 
the same causes as when the shaft of the bone has been 
fractured above the epiphysis. The treatment in every 
case is pretty much the same, although the degree of suc- 
cess which attends it will vary very much, agreeably to 
the extent to which the joint may have been implicated. 

The method recommended by Sir Astley Cooper, when 
the shaft of the bone has been broken as above described, — 
and, with some modifications and additions, it is applicable 
to the other cases, — consists "in bending the arm, and 
drawing it forwards to effect replacement ; then a roller 
should be applied while it is in the bent position. The best 
splint for it is one formed at right-angle, the upper portion 
of which should be placed behind the arm, and the lower 
portion under the forearm ; a splint must also be placed 
upon the anterior face of the upper arm, and both should 
be confined by straps : evaporating lotions should be used, 
and the forearm be kept in the flexed position and supported 
by a sling. In a fortnight, if the patient be young, passive 
motion may be gently begun to prevent the occurrence of 
anchylosis ; and in the adult, at the end of three weeks, a 
similar treatment should be pursued. But even after the 
most careful and judicious means which can be adopted, 
there is sometimes considerable loss of motion ; and when 
the accident has not been understood, or has been care- 



FRACTURES OF THE HUMERUS. 



167 




Iessly treated, the de- Fi S- 50 - 

formity and loss of mo- 
tion become very con- 
siderable." (See fig. 50, 
in which, however, the 
roller should have been 
represented as applied 
to the forearm and el- 
bow.) 

The mode of treat- 
ment generally adopted 
in this city consists in 

enveloping the limb, from the fingers to above the line of 
fracture, in a roller, the forearm being flexed and the frag- 
ments having been restored to apposition ; then a flat, or 
slightly grooved, rectangular splint is applied upon the an- 
terior face of the arm, forearm, and hand — or upon their 
inner aspect, the hand being semi-pronated, — and secured 
thus by means of a roller, a compress having been placed 
upon the point of the internal condyle if this has been se- 
vered ; the forearm should then be supported upon the chest 
by a sling. But if the fracture has involved the articular 
face of one or both condyles, it is advisable, in addition to 
the splint, to give increased support to the posterior face of 
the elbow. For this purpose a piece of pasteboard should 
be taken, sufficiently long to extend from three to four 
inches above the elbow, and for the same distance below it, 
and wide enough to envelope the joint laterally ; this should 
be notched at different points, so that after it has been soft- 
ened in hot water, it may be made to fit the elbow. Then, 
the arm having been bandaged, as before directed, and the 
anterior splint applied, this cap should be placed upon the 
posterior face of the elbow — care being taken to protect 
the bony projections from great pressure — and confined by 



168 FRACTURES OF THE HUMERUS. 

the roller which secures the other splint. At the end often 
days or two weeks, or earlier if all pain has ceased and if 
the bone has become sufficiently firm, passive motion should 
be resorted to from day to day, the condyles being sup- 
ported by the hand, and the angle of the anterior splint 
changed. After the lapse of eight or ten weeks, the con- 
finement may be omitted. It should be borne in mind that 
daily motion of the joint is of the greatest importance in 
the treatment of fractures about the elbow, but it should be 
practised cautiously and with the limitations above men- 
tioned. 

When the fracture is compound, the same indications are 
still to be accomplished as when it is simple, and the same 
plan is to be pursued. The splints must be so contrived, 
however, as to allow of frequent inspection and dressing of 
the wound, without requiring the removal of the whole ap- 
paratus. This may be effected by using splints of binders' 
board previously softened and moulded to the shape of the 
part, and large enough to give easy support to the frac- 
tured limb ; an aperture should be made in the splint oppo- 
site the wound, sufficiently large to permit of free exami- 
nation of the injury to the soft parts. The limb should be 
softly cushioned in the splints and secured to them above 
and below the wound, while the particular dressing re- 
quired for the latter may be laid over the aperture corre- 
sponding with it in situation and confined by the bandage 
of Scultetus. Or, when the wound is on the anterior face 
of the arm, the forearm may be enveloped in a roller, as 
in the other cases, and a bandage of Scultetus be applied 
immediately to the upper-arm, over the wound, or upon the 
dressing which covers it, while a curved angular splint sup- 
ports the posterior aspect of the whole limb. The forearm 
should be sustained by a sling in either case. 

Mr. Mayo contrived a very simple splint for the treat- 



FRACTURES OF THE HUMERUS. 



169 



ment of a case of bad compound fracture of the condyles, 
by which the requisite support was given to the bones, and 
the wound still allowed to discharge freely, and sufficiently 
exposed to be dressed without much disturbance of the 
limb. As such instances sometimes occur, it is well to 
have an acquaintance with the mode employed to treat 
them, as adopted by so high an authority as Mr. Mayo. 
The apparatus " consists of two splints joined together by 
two small bars, so as to leave a space between them for the 
elbow to fit into. One of the splints, B, in the wood-cut, 
(see fig. 51,) is made for the back part of the arm to lie 
upon, while the other, C, is for the forearm; the second 
splint terminates in a horizontal portion, D, for the hand to 
rest upon ; the intervening space, A, is formed by the two 
lateral bars, which are slightly curved outwards, to pre- 
vent pressure upon the joint." This splint should be 
padded, and the limb secured to it above and below the 
seat of injury, by an ordinary roller, while opposite the 
wound itself the bandage of Scultetus should be used for 
the same purpose, and also to retain suitable dressings upon 
the part. (Lonsdale, p. 189.) 



Fig. 51. 




With regard to the frequency with which the apparatus 
should be removed, and the fracture dressed, in cases of 
this injury generally, only conditional directions can be 
given. If, in a simple fracture, there be no unpleasant 
symptom or appearance after the limb is first dressed, the 

15 



170 



FRACTURES OF THE HUMERUS. 



bandage need not be removed for two or three days, and 
this quiescence of the limb is attended with many advan- 
tages, especially when the fracture has involved the joint 
directly or indirectly. But if the patient should complain 
of pain in the injured part, the envelopes should be removed 
at least once daily, and the injury examined; unless this 
attention is practised, sloughing of the soft parts, or trouble- 
some excoriations, will often occur. The first application 
of the roller and splints should be made carefully, so as to 
exert only a moderate degree of pressure, and to allow of 
the swelling which follows upon almost every fracture; 
and the compression made around the lower part of the 
limb should be proportioned to that upon the upper, else 
the soft parts below will become swollen and painful, and 
finally gangrene may ensue. 

In the wards of the Pennsylvania Hospital, in this city, 
it is rare that blood is taken from about the joint in case of 
fracture ; but the fragments are placed in apposition as 
speedily as possible, and confined, as above advised, — per- 
fect rest being considered a sufficiently powerful antiphlo- 
gistic remedy ; frequently, indeed, this is aided by the in- 
fluence of evaporating or sedative lotions, as diluted spirits, 
or lead-water. 

In compound fractures, the best local application to the 
seat of injury, after the means hereinbefore advised for 
the promotion of direct closure of the wound have failed, 
is a poultice, or the water-dressing : if the former be 
used, it should be changed at least twice daily, and as 
much oftener as may be required by the amount or nature 
of the discharge: as the wound contracts, and the sup- 
puration becomes very scanty, some stimulating lotion, 
or cerate, may be advantageously substituted. Passive 
motion should be resorted to, and diligently practised, as 
soon as the condition of the parts, internal and external, 
will allow ; this injunction is of the utmost consequence 



FRACTURES OF THE BONES OF THE FOREARM. 171 

after compound fractures near to, or involving, the joint, 
because it cannot be resorted to so early as in simple frac- 
tures, owing to the greater length of time requisite for the 
union of the fragments, and because also the joint has suf- 
fered more, in most cases, than in the other class of injury. 
In both, the rigidity of the parts may be lessened by fre- 
quently soaking the joint in warm water. 

Comminuted fractures of the humerus require no differ- 
ent treatment, as a general rule, from the simple, excepting 
rather nicer manipulation in reducing them, and in the 
application of compresses, and a somewhat longer con- 
finement. 

SECTION II. 

FOR FRACTURES OF THE BONES OF THE FOREARM. 

The complicated movements of the forearm, and the 
varied action of the numerous muscles necessary to effect 
them occasion, when one or both bones are broken, many 
forms of displacement of the fragments. To remedy these, 
so as to preserve unimpaired the mobility of the limb, it 
becomes necessary for the surgeon to resort to a variety 
of expedients, which it is the object of this section to set 
forth. 

In fractures of the forearm, whether of one or both 
bones, there is one common indication to be fulfilled, ex- 
cepting when the fracture has occurred very near to the 
extremities of the bones; — this is to preserve the inter- 
osseous space, which is almost always encroached upon 
by the fragments. 

1. For fractures of both bones. 

The displacement in these cases may be in the diameter 
or in the length of the forearm, or in both directions. 
Generally, there is not much difficulty in retaining the 
fragments in proper apposition after reduction. The mode 



172 FRACTURES OF THE BONES OF THE FOREAFwM. 

of accomplishing it, as it is commonly practised, consists 
in applying upon the anterior face of the forearm, a long 
compress which fits over the interosseous space, and then 
placing a straight, padded splint, sufficiently long to extend 
from the elbow to the ends of the fingers, upon the front, 
and another of the same length upon the back of the fore- 
arm, and securing them by circular and reverse turns of 
the roller. The width of the splints should be greater than 
that of the arm, so that the convolutions of the bandage 
shall not press the two bones towards each other. 

Sometimes considerable difficulty is experienced in coun- 
teracting a lateral angular displacement : but generally this 
may be overcome by applying a compress of suitable thick- 
ness over the point of deformity, at the side of the fore- 
arm, and by removing also, if necessary, the compression 
exercised upon the interosseous space at this point. 

After the forearm is thus suitably dressed, it is placed in 
a position midway between pronation and supination, — the 
palm of the hand towards the chest, the thumb, which is 
left uncovered, presenting upwards, — and supported in a 
sling in the flexed position. 

Both bones are not commonly broken at the same level, 
but this circumstance does not alter the general mode of 
treatment. 

Mr. Lonsdale objects to this mode of treatment, on the 
ground that the position in which the forearm is placed, — 
that of semi-pronation, — is not the one which is most cal- 
culated to insure perfection in the motions of the limb. 
The muscles which tend to throw the upper fragment of 
the radius in supination, are the supinator radii brevis and 
the biceps flexor cubiti, and, agreeably to Mr. Lonsdale's 
argument, these combined exert more power than the pro- 
nator muscle which operates upon this fragment, — the pro- 
nator radii teres ; hence the upper portion of the radius is 



FRACTURES OF THE BONES OF THE FOREARM. 173 

placed in a much more supine position than the lower, if 
the palm of the hand is turned towards the chest, with the 
thumb presenting directly upwards ; and if union of the 
two fragments of the radius takes place in this faulty rela- 
tive position, the extent to which pronation and supination 
can be effected will be impaired, as is not unfrequently 
noticed. 

To obviate this difficulty, Mr. Lonsdale recommends that 
the hand be placed supine, and that two straight splints be 
bandaged to the forearm, precisely as in the ordinary plan 
of treatment; then the forearm should be supported in a 
sling, the elbow approximated to the chest, and the hand 
projecting before the body. 

The splints should be retained for five or six weeks in 
fracture occurring to an adult, and for four or five weeks 
when a child is thus injured. 

In compound fractures of the forearm, only one splint 
can be used, as a general rule, with advantage. Tolerably 
good apposition of the fragments can be effected with a 
single splint, by a judicious arrangement of compresses and 
a roller, or bandage of Scultetus ; pressure upon the wound 
itself should be avoided, but, on the contrary, every facility 
should be offered to the escape of the pus. 

The " Ante-Brachial Hyponarthecia," of Sauter and 
Mayor is quite well adapted to the treatment of compound 
fractures of the forearm, of one or both bones. It is thus 
described by M. Cutler : 

"Composition. — A board of convenient width, a little 
longer than the forearm and hand, a cushion, a cord for 
arc-loops, and three cravats. 

" Application. — The fracture being reduced, the forearm 
is placed upon the cushioned board, a b (fig. 52), which is 
immediately suspended from the patient's neck by means of 
the arc-loops, e e, — the ring /, and the cervical cravat, g. 

15* 



174 



FRACTURES OF THE BONES OF THE FOREARM. 



Fig. 52. 




The second cravat, c, is now passed under the wrist, and 

crossed upon the back of the 
hand, the tails being then made 
to embrace the cushioned board, 
and knotted at its anterior bor- 
der, as represented at h. The 
third cravat is made to pass 
around the apparatus at its upper 
part, so as to confine the corre- 
sponding portion of the forearm, 
and is then knotted as the other. 
If it be necessary to counteract 
any lateral displacement, a 
fourth cravat may be made use of, to serve as a 'trac- 
tion ligature,' which will of course be knotted at the 
inner margin of the suspension-board." This apparatus 
leaves the forearm exposed to constant inspection, and 
suitable dressings can be applied to the wound without 
deranging the limb; if the discharge be very profuse, bran 
may be conveniently placed upon the board and around the 
arm to absorb the pus. When the patient lies down, the 
apparatus should be detached from the cervical cravat and 
placed upon a pillow, or suspended from the top of the bed, 
or from the ceiling. If it be deemed expedient, for greater 
security, to confine the whole limb, it can be very easily 
accomplished by selecting a longer board and cushion, ex- 
tending from the axilla to the extremities of the fingers, 
and employing a sufficient number of cravats arranged 
after the plan indicated. 

2. For fractures of the radius. 

This bone may be broken at its neck, at its carpal ex- 
tremity, or at any intermediate point. The first and the 
last cases should be treated as if both bones of the forearm 



FRACTURES OF THE BONES OF THE FOREARM. 



175 



were broken ; the hand may be placed in a state of semi- 
pronation, or in supination, as advised by Lonsdale. 

It sometimes happens that the lower fragment of the 
radius, when the fracture is near the carpal extremity, is 
driven very forcibly towards the ulna, so as to require the 
operation of a force gradually exerted and for a considera- 
ble time, to restore it to its natural line. For such cases 
Dupuytren recommended the following plan of treatment : 
" Take a bar of iron about an inch wide and of the length 
of the forearm, and which at its lower extremity, opposite 
the part corresponding with the wrist, curves downwards 
in a semicircle, to the concavity of which some buttons are 
placed at equal distances." Along the ulnar edge of the 
forearm, place a firm compress, extending from just above 
the extremity of the bone upwards, about an inch thick at 
the lower end and gradually tapering : upon this compress 
apply the splint, its straight portion extending from the 
elbow to the termination of the compress, and secure it in 
this position by a roller which, on reaching the hand, causes 
the latter to approxi- 
mate the curve of Fl £- 53, 
the bar, more or 
less, according to the 
amount of force re- /^p\^0^||^ 
quired to rectify the 
displacement of the 
lower fragment of the radius, with which the hand is con- 
nected. (See fig. 53.) 

Probably the most frequent variety of fracture to which 
the radius is subject is, the oblique fracture of its lower ex- 
tremity, just above its articular face, the line of fracture 
extending from the palmar surface of the radius obliquely 
upwards to its dorsal surface. Dr. J. Rhea Barton, of 
this city, has directed the attention of the profession par- 




176 



FRACTURES OF THE BONES OF THE FOREARM. 



ticularly to this injury, and established more clearly the 
fact that, the deformity which it occasions is due really to 
this fracture, and not to a dislocation of the carpus, as had 
been taught. 

In this accident, the lower fragment of the radius, and 
with it the carpus, is drawn upwards upon the back of the 
forearm, as is represented in the annexed drawing (fig. 54). 

Fig. 54. 




The treatment is very simple : place the fragments in ap- 
position by drawing down the hand, the upper part of the 
forearm being fixed ; then place a compress upon the pos- 
terior face of the lower fragment, and another on the an- 
terior face of the upper, and apply padded splints along the 
anterior and posterior faces of the forearm, as directed for 
the other fractures; the splints should extend from the elbow 
to the ends of the fingers. After the lapse of a week or ten 
days, passive motion of the wrist and finger joints should 
be commenced and repeated daily for five or six weeks, 
when the splints may be omitted. When the dressings are 
removed from time to time, the hand, and indeed the whole 
forearm also, should be bathed, otherwise the confinement 
will be attended with want of cleanliness of the part, and 
with a very unpleasant sour smell, disagreeable both to the 
patient and to the surgeon. 

The line of fracture sometimes assumes the opposite 
direction, extending from the dorsal face of the radius ob- 
liquely upwards to its palmar surface. The treatment is 



FRACTURES OF THE BONES OF THE FOREARM. 177 

the same as in the first variety of the injury, a slight change 
being made in the disposition of the compresses, to cor- 
respond with the different kind of deformity, as will at 
once suggest itself to the dresser. 

During the continuance of the splints, and for some time 
later, the forearm should be supported in a sling. 

3. For fractures of the ulna. 

The ulna may be broken in its shaft, or at the coronoid 
or olecranon processes. The first-named variety is treated 
after the same method as when both bones are involved ; 
fractures of the processes require a different plan. 

When the coronoid process is broken off from its bony 
and ligamentous connexions, the brachialis anticus muscle, 
which is inserted upon it, draws it up on the lower portion 
of the humerus ; and the chief difficulty in treating this ac- 
cident successfully consists in counteracting entirely the 
force of this muscle, so as to maintain the fragments in per- 
fect apposition. There is also another cause of failure, 
since when this process is detached, " like the head of the 
thigh-bone, it loses its ossific nourishment, and has no other 
than a ligamentous support. Its life is preserved by the 
vessels of the reflected portion of the capsular ligament 
upon the end of the bone, which do not appear capable of 
supporting the least attempt at ossific union." (Sir A. 
Cooper, op. cit., p. 406.) 

For the treatment of this injury, apply a roller from the 
ends of the fingers, around the forearm and about the 
elbow, making firm pressure upon the restored process, 
through the intervention of a compress, and then continue 
the roller around the arm, so as to confine the brachialis 
anticus : over the roller place an angular splint, extending 
from near the head of the humerus to the fingers, along the 
anterior surface of the limb, and retain it thus by a roller. 
The forearm should be supported in a sling, and the appa- 



178 FRACTURES OF THE BONES OF THE FOREARM. 

ratus should be worn for six or eight weeks, passive motion 
being resorted to very cautiously. The splint which is 
employed should be flexed at rather less than a right angle, 
in order that the brachialis anticus may be relaxed as 
much as possible, and every facility be afforded for a bony 
union of the fragments. 

The angular splints for the upper extremity may be 
made with the angle fixed, or this may be movable and 
changeable at pleasure, the two segments of the splint being 
fastened at the desired angle, by a pin traversing both por- 
tions: if the former arrangement be adopted, it will be 
necessary to have a multiplicity of splints made at differ- 
ent angles ; by the latter, the same splint will answer the 
purposes of all the others. 

The olecranon process is more frequently broken than 
the coronoid, and the reparation of the injury is equally, if 
not more, difficult. The triceps muscle acts upon the frag- 
ment of bone to great advantage, so that when the liga- 
mentous fibres are severed, which connect it with surround- 
ing points, the retraction is sometimes very great. 

The indication is, of course, to relax the muscle, so that 
the fragments may be kept in apposition; the forearm 
should be extended upon the arm, and some means should 
be resorted to for securing the broken surfaces together. 

Sir Astley Cooper advises the following plan of treat- 
ment: — "If there be much swelling and contusion, it is 
right to apply evaporating lotions and leeches for two or 
three days ; and after the inflammation is reduced, a ban- 
dage should be applied." — " If the swelling and inflamma- 
tion do not prevent it, the surgeon is, at once, to place the 
arm in a straight position, and to press down the upper 
portion of the fractured olecranon, until he brings it in con- 
tact with the ulna ; a piece of linen is then laid longitudinally 
on each side of the joint ; a wetted roller is applied above 



FRACTURES OF THE BONES OF THE FOREARM. 179 

the elbow, and another below it; the extremities of the 
linen are then to be doubled down over the rollers and 
tightly tied, so as to cause an approximation; thus the 
portions of bone are brought and held together ; a splint 
well padded is to be applied upon the fore part of the 
arm, to preserve it in a straight position, and confined to 
it by a circular bandage; the whole finally, is to be fre- 
quently wetted with spirits of wine and water." (See 

fig. 55.) 

Fig. 55. 




"In a month the splint is to be removed, and passive 
motion is to be begun; but, if it be attempted earlier, the 
olecranon will be separated from the shaft of the bone, and 
the ligament will become lengthened and weakened; all 
attempts at motion must therefore be made with the great- 
est gentleness." (Sir A. Cooper, op. cit. p. 410.) 

Another method of treating this fracture consists in ap- 
plying a roller from the fingers to the elbow, then drawing 
down the fragment of the olecranon to its natural situa- 
tion ; and while an assistant holds it thus, by means of a 
compress placed just above it, the surgeon makes a few 
figure-8 turns around the elbow, permanently confining the 
compress and the process of bone, and exhausts the roller 
upon the upper arm. A straight splint is now taken and 
laid upon the front of the limb, extending from near the 
head of the humerus to the wrist ; some cotton should be 
interposed between the splint and the bandage at the bend 
of the elbow, in order to fill up the vacuity at this point, — 
the forearm not being extended quite to the utmost, — and 
the whole secured by another roller. 



180 FRACTURES OF THE BONES OF THE FOREARM. 

The same precautions, with regard to the institution of 
passive motion, are to be attended to, as in the other 
method. 

The extension of the forearm, and the confinement of 
the fragment of the olecranon, may be effected also by the 
" olecrano-metacarpal cravat" of Mayor, as follows: — 
Extend the forearm and place upon its anterior face a 
pasteboard splint moulded to its form, and reaching from 
the lower third of the upper arm to the fingers : draw down 
the fractured process to the corresponding surface of the 
ulna, and upon it lay a compress, which should be held by 
an assistant ; then pass a cravat around the lower extre- 
mity of the humerus, so as to retain in place the splint and 
the compress, and knot it behind, leaving the tails hanging 
about half way down the back of the forearm ; to the palm 
of the hand, below the ball of the thumb, apply the centre 
of another cravat, and tie it upon the back of the wrist, 
thus securing the lower extremity of the splint, the tails of 
the cravat being free ; now tie the ends of the two cravats 
together. (See fig. 56.) 

Fig. 56. 




This method can scarcely be relied, upon for the perma- 
nent treatment of this form of fracture, when the other me- 
thods can be employed. 

Desault advises that the forearm should be maintained 
in a state between semi-flexion and extension, in case of 
fracture of the olecranon process, and that a splint slightly 
curved be applied on the anterior face of the limb, as in 
the plans already mentioned. 



FRACTURES OF THE WRIST AND HAND. 181 

In compound fracture of this portion of the bone, the 
limb should be extended by means of a splint laid upon its 
anterior face, and confined thus by a roller, which, however, 
should not cover the wound ; the edges of the latter should 
be retained in apposition by strips of adhesive plaster, and 
over it a piece of lint saturated with blood or solution of 
starch should be applied, the whole being enveloped, and 
the elbow tightly confined to the splint, by a bandage of 
Scultetus. The patient should be kept in bed with the arm 
extended on pillows, the hand elevated rather higher than 
the shoulder. If no unpleasant symptom occur, the dress- 
ing should be undisturbed for a week or ten days. Treated 
in this way, these injuries are sometimes very well reco- 
vered from. But if inflammation and suppuration come 
on, the accident must be treated as ordinary compound 
fractures presenting the same symptoms. 

Partial fractures of the bones of the forearm, those 
namely in which some of the fibres only of the bone are 
ruptured, the others being bent, require the same treatment, 
in general terms, as the complete fractures. After the line 
of the bone has been restored, however, by suitable mani- 
pulations, there is usually less disposition to a reproduction 
of the deformity, and hence less compressing force is re- 
quired to counteract it ; generally, too, union takes place 
sooner than in the other cases, and the splints need not be 
worn so long as in the latter. 



SECTION III. 

FOR FRACTURES OF THE BONES OF THE WRIST AND HAND. 

1. Fractures of the carpal bones are almost necessarily 
compound and attended with much injury to the soft parts ; 

16 



1S'2 FRACTURES OF THE WRIST AND HAND. 

they require no especial apparatus to keep them in place. 
The best plan ot treatment in such cases is, to adapt a 
splint to the lower part of the forearm and hand, increasing 
in width at the wrist, being retained lightly in this situation 
by a roller, or bandage of Scultetus ; if the wound is on the 
palmar surface of the wrist, the splint should be applied to 
the back of the forearm and hand, and vice versa. If, as 
is generally the case, there is no probability of securing 
direct closure of the wound, poultices, or water-dressings, 
should be laid upon it, at first, or the treatment by irri- 
gation should be adopted, and other applications used as 
required : the forearm and hand should be supported in a 
sling, or should repose upon a pillow, as most expedient. 

2. Simple fractures of the metacarpal bones are, in ge- 
neral, attended with but little displacement ; after the frag- 
ments have been restored to apposition, they are easily 
retained in situ by merely laying a compress upon the bone, 
and confining it thus, with the hand and forearm upon a 
broad splint as above. 

3. Simple fractures of the bones of the fingers require 
for their treatment merely that the fingers shall be sup- 
ported by a thin strip of pasteboard placed on each side of 
them, and confined by a piece of tape applied in circular 
turns. For greater security and to insure perfect repose 
to the injured ringer, the hand and forearm should be bound 
to a splint, as in the cases just considered, and supported 
in a sling. 

4. Compound fractures of the metacarpal and phalangeal 
bones are often met with, as occasioned by the bursting of 
firearms, the explosion of rocks, and by the hand becoming 
entangled in machinery. Such injuries appear very formi- 
dable at first, and as if beyond reparation ; but the hand is 
of such vast importance to the patient, — and the accident 
generally happens to those who earn their subsistence by 



FRACTURES OF THE WRIST AND HAND. 183 

their daily labour, — that an attempt at saving it should be 
made, and the most unpromising cases do very often re- 
cover with very useful hands. 

A splint long enough to extend from the elbow to the 
ends of the fingers, or a little beyond them, and grooved on 
its palmar portion to receive the fingers (see fig. 57), should 
be padded with cotton, or covered with a poultice or other 
suitable dressing, and placed underneath the limb : a roller 

Fig. 57. 




should be passed around the forearm and splint, to retain 
the latter in place, and this, with the weight of the dress- 
ings that are laid upon the hand, will be found in most 
cases to be sufficiently retentive for the latter. Generally, 
the continued application of cold water upon the lacerated 
parts, will prove the best and the most agreeable dressing 
that can be employed ; it should be used as advised under 
the head of irrigation, in the first part of this volume. The 
feelings of the patient form the best guide as to the length 
of time during which this application should be retained ; 
so long as he finds it comfortable, it may be continued ; so 
soon as he complains of increasing pain in the injured part, 
or if he becomes chilly under its use, it will be best to sub- 
stitute for it a warm poultice, or folds of soft lint saturated 
with warm water; and the dressings should be varied to 
suit the particular conditions of the wound. When there 
is free suppuration, particularly in warm weather, the bran 
dressing will be found very serviceable, as it not only ab- 
sorbs the discharges, but covers the injured parts and ren- 
ders it less likely to be infested with vermin, — a source of 
much trouble and annoyance both to the surgeon and the 



184 FRACTURES OF THE WRIST AND HAND. 

patient. (Some of the strong aromatic oils are of service in 
destroying these nuisances ; but it is generally necessary 
to dislodge them from their burrowing-places by means of 
the dissecting forceps, and by injecting a stream of water 
upon them from a small syringe.) 

After the suppuration has in a measure ceased, and the 
wounds have assumed the appearance of healthy ulcers, 
the hand may be placed upon a flat splint, of the same 
shape as the other, and the bones pressed into proper line, 
by inserting pledgets of lint between the fingers and using 
gentle compression upon the whole hand by the folds of a 
bandage of Scultetus, enveloping both the hand and the 
splint ; the tendency to recurring displacement of the frag- 
ments of bone is so slight in these cases, that very little 
force is requisite to keep them in tolerable apposition. 

During the early part of the treatment, the patient should 
be kept in bed, with the arm reposing upon pillows, the 
hand somewhat elevated ; in the latter stages, he may be 
allowed to leave the bed, with the arm supported in a 
sling. 

The disposition of the pus to run underneath the soft 
parts, forming collections at points remote from the wound, 
should be counteracted by position, by compression, and 
finally, if it can be prevented in no other way, by incisions 
practised wherever a deposit is formed. 



CHAPTER V. 

ON THE APPARATUS AND DRESSINGS FOR FRACTURES 
OF THE BONES OF THE LOWER EXTREMITY. 

SECTION I. 

FOR FRACTURES OF THE OS FEMORIS. 

Greater difficulty is experienced in the treatment of 
fractures of the femur, than in those of any other bone. 
The constant action of powerful muscles ; the injurious 
effects of pressure upon the soft parts, from long-continued 
position, and from the compression of bandages ; the hurt- 
ful influence upon the general health of protracted confine- 
ment, and the direct impression upon the system resulting 
from the injury itself, are all to be combated in the same 
case. The attention which has been devoted to the con- 
sideration of this subject, has been proportioned to its im- 
portance. 

The proper position in which the thigh shall be main- 
tained during the treatment is the main point of discussion 
among surgeons, some preferring the flexed, others the ex- 
tended position of the limb ; a variety of apparatus, more 
or less complicated in structure and arrangement, has been 
contrived with reference to each plan of treatment. 

1. Modes of treatment, the thigh being in the flexed 
position. — This position is most in vogue in Great Britain ; 
it was first particularly recommended by Mr. Pott, who 
founded it. upon the idea that it is possible " to put the limb 

16* 



186 FRACTURES OF THE OS FEMORIS. 

into such a position as shall relax the whole set of muscles 
belonging to, or in connexion with, the broken bone." This 
idea is manifestly incorrect, since the position which re- 
laxes the flexor muscles renders the extensors more tense; 
that which approximates the extremities of the adductors 
has the reverse effect upon the abductors. 

The following is the plan of treatment adopted by Mr. 
Pott : — " The position of the fractured os femoris should be 
on its outside, resting on the great trochanter ; the patient's 
whole bodv should be inclined to the same side; the knee 
should be in a middle state between perfect flexion and ex- 
tension, or half-bent ; the leg and foot, lying on their out- 
side also, should be well supported by smooth pillows, and 
should be rather higher in their level than the thigh ; one 
very broad splint of deal, hollowed out and well covered 
with wool, rag, or tow, should be placed under the thigh, 
from above the trochanter quite below the knee ; and ano- 
ther, somewhat shorter, should extend from the groin to 
below the knee on the inside, or rather, in this posture, on 
the upper side. The bandage should be of the eighteen- 
tail kind, and when the bone has been well set, and the 
thigh well placed upon the pillow, it should not, without 
necessity, (which necessity will, in this method, seldom 
occur.) be moved from it again, until the fracture is united ; 
and this union will always be accomplished in more or 
less time, in proportion as the limb shall have been more 
or less disturbed." (Cooper's Surg. Diet.) The chief and 
sufficient objections to this plan of treatment are, that the 
means employed are insufficient to keep the ends of the 
fragments in apposition, and too insecure against sudden 
and accidental movements of the limb, or of the whole 
body: and that the pressure exerted upon the trochanter 
for the space of many weeks is too great to be safely 
borne. 



FRACTURES OF THE OS FEMORIS. 187 

There are some cases, however, in which this position 
may be adopted as a temporary one ; these will be men- 
tioned hereafter. 

Sir C. Bell recommended another method of treating this 
class of injuries in the flexed position of the thigh : — The 
patient lies upon his back, while the limb is supported upon 
a double inclined plane, one portion of which extends from 
the tuberosity of the ischium to the ham, and the other 
from the ham to the heel ; straight splints are confined to 
the outer and inner sides of the thigh. Numerous appa- 
ratus have been contrived, in modification of the origi- 
nal suggestion of Bell, some of which are much used in 
England. 

2. The plan of treatment by the straight position of the 
limb was first employed by Desault. In this method, a 
constant extending and counter-extending force is main- 
tained upon the fragments, while lateral pressure is exerted 
upon the limb by means of splints and bandages. The ori- 
ginal apparatus of Desault has been modified and improved 
upon, in various ways, by European and American sur- 
geons, so that fractures of the thigh may be more success- 
fully treated in the straight position, than in any other. 

The os femoris may be broken at its condyloid, or tro- 
chanteric extremity, or at any point in its shaft ; and al- 
though the general plan of treating the injury, at whatever 
part the fracture may have occurred, is the same, yet there 
are some minor points of difference, which are neverthe- 
less of importance in practice. 

1. For fractures occurring in the shaft of the bone. 

The injury may be simple or compound, and the line of 
fracture transverse or oblique. Displacement of the frag- 
ments almost invariably occurs, even when the bone is trans- 
versely broken, for the force which caused the fracture 



188 FRACTURES OF THE OS FEMORIS. 

nearly always deranges the axis of the bone, pushing the 
two portions from contact with each other, and then the 
muscles have uncontrolled action, and draw the lower frag- 
ment upwards, above, or underneath, the superior. Even 
if the contact of the extremities of the two portions, at the 
point of fracture, be not completely sundered by the origi- 
nal violence, the muscles which pass from the pelvis to the 
lower extremity of the femur will act upon the latter, 
and thus derange the natural line of the bone. But when 
the fracture is oblique, shortening of the limb is a neces- 
sary consequence, and its degree will depend very much 
upon the muscular development of the patient. 

The solution of continuity may occur at any point be- 
tween the smaller trochanter and. the condyles, but its most 
frequent seat is within the lower two-thirds of the bone. 
The inferior fragment is drawn upwards and, generally, in- 
wards by the extensor and adductor muscles, while the 
superior is elevated at its lower extremity by the action of 
the iliacus internus and psoas magnus, and this tilting-up 
of the fragment will be greater or less, as the fracture is 
near to, or remote from, the insertion of these muscles. 
The direction which the upper portion of the bone will 
assume will be modified also by the operation upon it of 
the glutaeus maximus, if the fracture be above the middle 
of the shaft, — it will be thrown outwards. The choice and 
management of the apparatus employed to treat a case of 
fracture of the shaft of the femur must, of course, be based 
upon its adaptation to the counteraction of these causes of 
deformity. It will be most convenient, with reference to 
this point, to consider, first, the different kinds of apparatus 
used in the treatment of these injuries, in the flexed posi- 
tion of the limb; and, secondly, those adapted to the 
extended position. 



FRACTURES OF THE OS FEMORIS. 189 

The plan proposed by Pott has been already described, 
and the objections to it have been stated : it should not be 
adopted in ordinary cases as a permanent method of treat- 
ment, but in some instances it may be used with advantage. 
Thus, when there is much contusion of the soft parts, or in 
cases of compound fracture with the wound on the under 
surface of the thigh, as may perhaps happen occasionally, 
it is the only plan which can be resorted to, — temporarily 
in the first class of cases, and as a permanent mode in the 
latter. 

The apparatus contrived by Sir Charles Bell consisted 
of two boards, ten or eleven inches wide, one of which was 
made to extend from the tuberosity of the ischium to the 
popliteal flexure, and the other from the latter point to the 
heel : these two portions of the apparatus were united at an 
angle under the knee-joint, while their other extremities 
were connected by a horizontal piece, which served also 
to support the double inclined plane upon the bed. Holes 
were pierced along the margin of the inclined planes, in 
which pegs were inserted to steady the limb. When about 
to be used, the apparatus was placed upon a mattrass, the 
inclined surfaces covered with a cushion, and the limb laid 
upon it, so that the under surface of the knee should corre- 
spond with the angle of the plane, and the tuberosity of 
the ischium should check against the upper extremity of 
the horizontal board. A lath splint was bound to the upper 
surface of the thigh, and another along the inner face of 
the same. 

Many modifications of this simple apparatus have been 
contrived since the original was proposed. Mr. Lonsdale's 
book contains a description of the one which was — at the 
time he wrote, 1838, — in ordinary use at the Middlesex 
Hospital, London, and which, he thinks, " possesses all the 



190 



FRACTURES OF THE OS FEMORIS. 



advantages that the more complicated ones are said to 
have." It differs from the one just described in having the 
planes joined by means of a hinge at the point correspond- 
ing with the knee ; and the same sort of union exists be- 
tween the thigh-piece and the horizontal frame, while the 
portion on which the leg reposes may be fixed at any angle 
upon the latter, by means of a serrated edge. " The letter 
A marks the screw that secures a slide in the thigh-portion 

Fig. 58. 




of the plane, to allow of the latter being adapted to limbs 
of different lengths." (See fig. 58.) A slide, having a foot- 
board attached to it, could be very easily adapted to the 
lower plane, so that it might be fastened at a suitable dis- 
tance from the angle, to correspond with the length of 
the leg. 

In making use of this apparatus, the length of the thigh 
and leg portions of the plane should be made to agree with 
that of the unbroken thigh and leg ; " the points from which 
the measurement should be taken are the tuberosity of the 
ischium and the angle of the knee," and the latter point 
and the heel; "and the plane should be applied to the sound 
limb first, to see that it corresponds exactly with the points 
above mentioned." (Lonsdale, p. 298.) It is advised to 
have the cushion made of flannel folded several times, as 
this is supposed to offer a more smooth and level sur- 



FRACTURES OF THE OS FEMORIS. 



191 



face, upon which the limb shall rest, than if pillows are 
employed. The whole limb is then gently raised, the thigh 
and leg being flexed, and the seat of fracture carefully- 
supported, the plane, having a bandage of Scultetus ar- 
ranged upon the thigh-portion of it, slid underneath, and 
the limb now lowered gradually down upon it. Care 
should be taken that the angle of the knee corresponds 
exactly with that of the plane, and that the tuberosity of the 
ischium presses well against the upper extremity of the 
apparatus. The hand should be passed gently underneath 
the limb, and the cushion smoothed. The proper angle of 
the plane must be determined by the degree of elevation 
which may be required to make the line of the lower frag- 
ment level with that of the upper, — the latter, as has been 
already pointed out, being tilted more or less upwards by 
the action of the psoas magnus and iliacus internus muscles. 
An assistant should support the limb while the surgeon 
confines upon the outer, upper, and inner aspects of the 




ihigh three splints of the length of the bone, by means of 
the bandage of Scultetus. The limb is secured to the plane 



192 FRACTURES OF THE OS FEMORIS. 

by a roller, the foot is attached to the foot-board by the 
same means, and the legs are inserted into the holes made 
for them. The annexed drawing, taken from Mr. Lons- 
dale's book, p. 302, " represents the apparatus when pro- 
perly applied. The lines A, B, show the two important 
points that are to be attended to ; — A, that the angle of the 
knee corresponds with the angle of the plane — B, that the 
tuberosity of the ischium presses well against the upper 
end." (See fig. 59.) 

Any disposition to the lateral angular deformity, in con- 
sequence of the glutasus maximus muscle acting upon the 
upper fragment, may be easily counteracted, by directing 
the apparatus outwardly from the middle line of the body, 
thus giving the lower fragment a direction parallel and 
continuous with that of the upper. 

The chief modification of this simple apparatus is that 
of Mr. Amesbury, who contrived it to remedy the objec- 
tions which appeared to him to be well-founded against the 
other : these objections were, that it allowed of motion of 
the pelvis, and consequently of the upper fragment, thereby 
disturbing the apposition of the broken extremities of the 
bone, and that it did not allow of sufficient extension being 
made. It will be seen, by examining the double inclined 
plane above described, that the pelvis is not well confined, 
and that the counter-extension is effected chiefly by the 
weight of the body, aided by the pressure of the apparatus 
against the tuberosity of the ischium, and by the attach- 
ment of the upper fragment to the thigh-portion of the 
plane, — while the extension is made by the weight of the 
leg and its confinement, together with that of the foot, to 
the lower plane and foot-board. 

Dr. Spaulding, of Buffalo, has been very successful in 
treating these injuries by the inclined plane. He fixes the 



FRACTURES OF THE OS FEMORIS. 



193 



pelvis more securely, by allowing the horizontal portion of 
the plane to extend high up, so that the tuberosity of the 
ischium shall rest upon it 

Mr. Amesbury's apparatus is much more complicated. 
It consists of three parts, exclusive of straight splints and 
straps : one portion, a, corresponds with the thigh, another, 
7, with the leg, and the third, c, with the foot. (Fig. 60.) 

Fig. 60. 




There are two thigh-pieces to each apparatus, " one is 
bevelled off at the lower end to the right ; and the other to 
the left," to render the shape of the upper part of the plane 
conformable to that of the thigh,— a perfectly-formed thigh 
being not straight, but curving a little inwards towards the 
knee. The thigh and leg-pieces are connected together by 
a hinge-joint, fastened by a pin, d. The foot-board is fitted 
upon the lower plane at a right angle, and may be fixed at 
a greater or less distance from the angle of the two planes, 
by means of a pin or a screw. The length of the thigh- 
piece may be adapted to any limb, by means of a sliding 
plate which is arranged at its upper part, and which may 
be fixed as required by a screw. The two portions of the 
plane are connected underneath by a steel rod, e, and the 
angle of the plane may be altered at pleasure, by varying 
the point of fixation of this rod to the under surface of the 
thigh-piece, a rack being there placed with several projec- 
tions, each of which has a hole bored through the middle, 
for the purpose of receiving a bolt which also perforates 

17 



194 FRACTURES OF THE OS FEMORIS. 

the extremity of the rod. At the back of the sliding plate, 
a couple of bars are placed., which serve to render the plate 
more secure, and also to confine the pelvis-strap which 
retains the apparatus in apposition with the ischium. 

In applying this apparatus, it should first be adapted to 
the sound limb, in order that the proper length may be 
ascertained. Then, the requisite angle having been given to 
the planes, and their surfaces smoothly and evenly cushion- 
ed by means of flannel, the broken limb should be carefully 
deposited upon the apparatus, a roller having been previ- 
ously applied from the foot to the knee. The shoe, a, (see 
fig. 61,) should now be buckled over the foot securely, and 
the pelvis-strap passed between the bars and the plate of 
the sliding portion of the thigh-piece. The leg should be 
confined to the lower plane, by a roller, d, and the frag- 
ments of the femur properly adjusted, by extension and 
counter-extension, and retained in position by three straight 
splints, one on the outer, e, another on the upper,/, and the 
third on the inner, face of the thigh, in which situations 
they are secured by the straps, g, g, g, fixed to the back of 
the apparatus. " The pelvis-strap, h, should now be car- 
ried round the limb under the strips of leather, on the backs 

Fig. 61. 




of the short splints, and made to cross on the outer side, 
and then the buckle-end with the sliding-pad should be con- 
ducted round the pelvis, and made to meet the other end 
in front, where it should be buckled." 



FRACTURES OF THE OS FEMORIS. 



195 



When there is much inflammation, Mr. Amesbury omits 
the front splint, and applies evaporating lotions, &c. &c. 

When the apparatus is thus securely arranged, it may 
be placed on its side, or rest upright. Mr. A. thinks that 
" half way between the side and the heel is a better posi- 
tion for a continuance. I generally," he continues, " place 
the apparatus upright, or a very little rolled outwards. It 
is maintained in either of these positions by pillows, assist- 
ed by a couple of tapes, i, i, carried from the lower end of 
the apparatus to the foot of the bed." 

This apparatus certainly seems to offer much more secu- 
rity than the more simple one before described, and by it, 
according to the testimony of its author and many others, 
cures are effected of fractures of the thigh, without appa- 
rent shortening of the limb. 

Professor Nathan R. Smith, of Baltimore, has construct- 
ed a very light and portable double inclined plane, for the 
treatment of these injuries, which is believed to be equally 
valuable and efficacious. A full account of it may be seen 
in " Gedding's Baltimore Medical and Surgical Journal," 

Fig. 62. 




vol. i. 1833. It allows of suspension of the limb, and a 
gentle swinging motion. The annexed figure will convey 
an idea of its construction. (See fig. 62.) 



196 FRACTURES OF THE OS FEMORIS. 

The hyponarthecia of Mayor and Sauter, is a modifica- 
tion of the same principle, — a double inclined plane, upon 
which the thigh and leg are confined, in the same manner 
as is the arm in the hyponarthecia for the upper extremity ; 
as in the latter case, the apparatus is suspended from the 
bed or ceiling. Those who would see a drawing of this 
apparatus, are referred to the book of Mayor, to that of 
C utler, or to that of Dr. H. H. Smith. 

The only way in which any individual can form a satis- 
factory opinion, as to the real comparative efficacy of the 
treatment of fractures of the thigh by position, is to test it 
for himself. The statements respecting it are of the most 
opposite kind, and by surgeons of equal eminence, — among 
whom are Amesbury, Lonsdale, Cooper, Bell, Earle, in 
favour of it, while Liston, Fergusson, and most of the con- 
tinental and American surgeons prefer the method by ex- 
tension. 

This latter mode of treatment, as it is now generally 
practised, was proposed by Desault. The apparatus em- 
ployed by him consisted of two straight splints rather 
broader than the antero-posterior diameter of the limb, ta- 
pering gradually from the upper to the lower end, — one 
long enough to extend from the crest of the ilium to four 
inches beyond the foot, and the other from the perineum to 
the sole of the foot along the inner side of the limb ; near 
the upper end of the long splint a hole was perforated for 
the attachment of the counter-extending band, and a notch 
was cut at the lower extremity, with a perforation just 
above it, for the securing of the extending strap. The rest 
of the apparatus consisted of a splint-cloth ; long pads fiiled 
with chaff, to equalize the pressure of the splints along the 
outer and inner faces of the limb ; a counter-extending 
band, to pass between the pubis and the upper part of the 
thigh, and to be attached to the upper extremity of the long 




FRACTURES OF THE OS FEMORIS. 197 

splint, and an extending band, for the purpose of firmly 
connecting the foot with the lower end of the same 
splint ; lateral pressure was made by means of seve- 
ral strips of muslin, which drew the splints and the 
pads firmly against the limb on each side, while the 
thigh was enveloped in a bandage of Scultetus. 

The objection to this particular apparatus is that, 
the extending and counter-extending forces do not 
act sufficiently parallel with the axis of the limb. 
This difficulty is obviated by the very simple modi- 
fication which Dr. Physick made of the apparatus 
of Desault. This consisted in making the outer 
splint long enough to extend from the axilla to about 
four inches beyond the sole of the foot, and in at- 
taching to its inner side, at about two inches above 
its lower end, a block, grooved on its inner margin, 
and broad enough to reach the line of the middle 
of the foot (fig. 63) ; the other component parts of 
the apparatus are the same as are used in Desault's. 
The counter-extending band is best made by filling 
a narrow bag of muslin, about three-fourths of a 
yard long, firmly with bran, or oat-chaff, so as to 
form a cylinder of an inch in diameter; to. each 
extremity a piece of strong tape should be securely 
sewed, for the purpose of attaching the band to the 
upper extremity of the splint ; when this is applied, 
a piece of soft buckskin should be interposed be- 
tween it and the skin, as a preventive of excoria- 
tion and chafing. Extension is best effected by 
means of a gaiter, similar in shape to that repre- 
sented in the annexed wood-cut (see fig. 64) : it 
should be made of strong muslin lined with soft buckskin, 
both to be cut " bias," so that the gaiter will set smoothly 
to the ankle ; stout tapes should be attached to its lower 

17* 



198 



FRACTURES OF THE OS FEMORIS. 



Fig. 64. 




edge, one on each side, to 
make traction upon it and 
to secure it to the splint, and 
three or four shorter tapes 
should be sewed to each 
free margin, to tie the gaiter 
upon the anterior part of the 
foot. Previous to its appli- 
cation, the ankle should be 
bathed with whiskey, or soap-liniment, or spirits of cam- 
phor, and enveloped smoothly in a pad of soft carded cot- 
ton : then the gaiter should be fitted nicely to the part, and 
tied. The following plan may be pursued in arranging and 
applying this apparatus, or that of Desault: Place upon the 
mattrass, and in a position to correspond with the frac- 
tured limb, the splint-cloth — a piece of muslin about two 
yards long, and as wide as the length of the inner splint, — 
and upon this arrange the strips of a bandage of Scultetus ; 
then lay the patient carefully upon the mattrass, so that the 
broken thigh, previously divested of clothing, shall repose 
upon the strips and the splint-cloth ; next pass the perineal 
band under the buttock, and tie the gaiter around the ankle, 
as before directed ; the limb being carefully steadied bv an 
assistant, roll the splints in the cloth, commencing at the 
margins, leaving only space enough between each side of 
the limb and the corresponding splint, thus enveloped, to 
admit of the presence of the junk-bag, — the long pad before 
spoken of. (The proper rolling up of the splints requires 
some time and trouble — they should be tightly wrapped, so 
that when pressure is used laterally upon the limb, they 
may not slip, and thus leave a larger space between them 
and the leg than is compatible with the accomplishment of 
one of the objects for which they are employed, viz., the 
exercise of an equable and firm compression upon the limb, 



FRACTURES OF THE OS FEMORIS. 199 

by the aid of the junk-bags.) The splints being thus pre- 
pared for use, extension and counter-extension should be 
made by assistants, the one grasping the foot and ankle, and 
the other fixing the pelvis — by one hand passed between 
the thigh and the pubis and ischium, and the other on the 
outside of the hip — while the surgeon coaptates the frag- 
ments and adjusts the shape of the thigh ; he then arranges 
the bandage of Scultetus, and afterwards presses the junk- 
bags and the splints firmly against the sides of the limb ; 
the counter-extending and extending bands should now be 
tightly secured to their corresponding extremities of the 
long splint, — the tapes attached to the gaiter passing over 
the grooved margin of the block, before described. To 
secure the limb in this adjustment, three or four strips of 
muslin should be passed underneath the apparatus, at inter- 
vals along the limb, and tied across, the knot being made 
upon the edge of one of the splints, to prevent it slipping ; 
and a broad band should likewise confine the upper part of 
the long splint to the side. It is sometimes advisable to 
give additional support to the foot, by tying a strip of mus- 
lin around it, and then pinning the ends to the splint cloth. 
An arched frame of wire, or of hoop, should be placed over 
the foot, to protect it from the pressure of the bed-clothes. 

The limb should be placed out from the axis of the body, 
particularly in those cases where the fracture is at such a 
point as that the glutseus maxirrms muscle will draw the 
upper fragment of bone outwards. 

It is well to use the bandage of Scultetus during the first 
few days after the injury, since it makes gentle and equable 
pressure upon the muscles of the thigh, and assists some- 
what to keep the fragments of the bone in apposition ; after 
the first week or ten days, however, it is probably as well, 
or better, to remove it, leaving the thigh exposed to the eye 
of the surgeon. 



200 FRACTURES OF THE OS FEMORIS. 

Cold lotions should be applied at any time, as they may 
be called for by the condition of the soft parts ; anodyne 
liniments are sometimes of service in allaying muscular 
irritability, and in alleviating pain in the limb. 

'Very excellent cures may be effected, undoubtedly, by 
the use of this apparatus ; but it is one which demands, in 
its employment, the greatest care and attention on the part 
of the attendant. There are some points to which the 
author would call particular notice : — the accidents chiefly 
to be feared, as directly connected with the use of this 
splint, are, excoriations and sloughs upon the heel, on the 
inner side of the knee, at the prominence of the inner con- 
dyle of the femur and the corresponding point of the tibia, 
and in the perineum. These are not necessary accom- 
paniments of the mode of treatment now under considera- 
tion, and with proper care they will never occur, but with- 
out great watchfulness they are exceedingly likely to 
happen ; they may be avoided in this way : — 

The gaiter should be unbound daily, so long as it is worn, 
and the instep, ankles and heel carefully examined. During 
the first week, or ten days, the gaiter should be loosened 
every morning and evening, and these parts bathed with 
whiskey, or soap-liniment ; this may be done without in the 
slightest degree deranging the fragments of bone, simply 
by turning up the lower ends of the junk-bags, so as to 
give room for the introduction of the hand between the 
splint and the foot, — the strips which maintain the lateral 
pressure being securely tightened. The inner side of the 
knee should be gently rubbed in the same way, and a little 
indentation should be made in the junk-bag, corresponding 
with the bony prominences of the femur and tibia at this 
point. The perineal band should be loosened daily, — the 
limb being supported the while by an assistant, and the 
lateral compression maintained, — and the parts upon which 



FRACTURES OF THE OS FEMORIS. 201 

it presses bathed, as the others. Whenever the apparatus 
is thus re-adjusted, renewed extension and counter-extension 
should be made, and in order that this may be persevered 
in until the end of the treatment, it is highly necessary that 
the splints shall be so closely wrapped in the cloth, and 
shall approach the limb, on each side, so nearly, as that 
firm lateral pressure may be kept up, and thus the strain 
upon the foot and perineum rendered very supportable. 

It is advisable, oftentimes, to vary the means by which 
the extension and counter-extension are effected. Thus, 
after having used a perineal band of the dimensions and 
form above recommended, let one be substituted flattened 
in shape and broader, so as to act upon a larger surface, 
and thus relieve that part which has been already pressed 
upon. So with regard to the gaiter, — it will occasionally, 
perhaps, be well to substitute for this a handkerchief folded 
into the cravat-shape, and applied so as to press upon the 
instep and the point of the heel, the tails passing from the 
sides of the foot, parallel with the axis of the limb, and 
reaching to the ex- _. ^ 

r rig. 65. • 

tremity of the long 
splint upon which 
they are tied. (See 
fig. 65.) Another 
mode of making 
extension is by 
means of adhesive 
plaster, as follows : — Cut two very long strips, of an inch, 
or more, in width, and apply them to the leg, commencing 
at a point, halfway between the foot and the knee, descend- 
ing spirally to the side of the foot, one on each side ; then, 
when adhesion between the strip and the integuments has 
become firm, attach the strips to the extremity of the long 
splint, as by the other method. This plan was first em- 




202 FRACTURES OF THE OS FEMORIS. 

ployed by Dr. E. Wallace, of this city, while Resident 
Surgeon at the Hospital; he used it as a substitute for the 
gaiter, which had produced excoriation just above the heel ; 
the author had the pleasure of witnessing the complete suc- 
cess which attended the operation of this novel extending 
band, both in the instance in which it was first tried and 
in several other cases, and he would recommend it highly, 
as being perfectly secure and efficacious. It may be pro- 
per to make use of a few turns of a roller, or of a bandage 
of Scultetus, to compress the adhesive strips against the 
leg, but this is scarcely called for, since the junk-bags ex- 
ercise sufficient pressure of themselves. 

If there is any disposition to excoriation or sloughing 
upon the points of the malleoli, pressure should be taken 
off from them, by not allowing the junk-bags to extend so 
low down. The same accident may be prevented from 
occurring upon the point of the heel by placing a cushion 
just above it, under the leg, so that the weight of the limb 
shall not fall upon this point. The same simple method 
may be resorted to when a similar accident threatens the 
hips or back, — a judicious arrangement of pillows will 
often obviate much mischief, aided also by stimulating lini- 
ments applied to the parts. When, in spite of these pre- 
cautions, sloughing does occur — as it sometimes will in old 
persons, or in those of lax fibre, — all pressure should be at 
once withdrawn from the affected surface, and the separa- 
tion of the dead tissue aided by the application of poultices ; 
afterwards stimulating washes should be used, among the 
best of which is Labarraque's solution of the chloride of 
soda, diluted with three or four parts of water, and applied 
to the ulcer upon rags, or, if the slough has extended be- 
neath the skin, injected from a syringe. 

There is one objection to the employment of this appa- 
ratus of Desault and Physick in the treatment of fractures 



FRACTURES OF THE OS FEMORIS. 203 

of the thigh, occurring particularly in the upper third of 
the shaft — (and the same objection is applicable to the 
treatment by extension in the straight position, generally) : 
it is sometimes impossible to counteract, by it, the defor- 
mity which arises from the powerful contraction of the 
iliacus internus and psoas magnus muscles, which tilt up 
the lower end of the upper fragment. When this action is 
but slight it may be overcome, gradually, by compression 
with a splint bound upon the anterior face of the thigh, or 
by a compress, or, finally, by a little elevation given to the 
lower fragment by means of a folded sheet placed beneath 
the thigh, at this point. But in very athletic patients the 
muscles in question may contract too powerfully, and then 
these means will fail; if the straight splints are retained, 
a permanent deformity will ensue and the limb will be al- 
ways weak, in consequence of the imperfect apposition of 
the fragments. In such cases as these, the double inclined 
plane should be substituted for the other apparatus. 

The apparatus of Desault, improved as above described, 
is, we think, the best which has yet been contrived for the 
treatment of fractures of the thigh, in the extended position. 
There are many others, however, of perhaps equal note, 
and of these an account will now be attempted. 

Boyer's apparatus is composed of a long splint for the 
external side of the limb, with a movable footboard con- 
nected therewith ; of two straight splints for the anterior 
and inner faces of the limb; a belt enclosing the upper part 
of the thigh and the groin, and giving a "point d'appui" to 
the upper extremity of the outer splint ; straps to secure 
the foot to the foot-board ; cushions, and tapes to confine 
the apparatus upon the limb. The outer splint is the only 
complicated part of the apparatus. It is about four feet 
long and as many inches in width; from its lower extre- 
mity upwards, along about half its length, runs a groove 



204 FRACTURES OF THE OS FEMORIS. 

in which a screw plays ; the upper end of the screw turns 
upon an iron plate, while the other extremity, at the end of 
the splint, has a key attached to it, by which it is made to 
revolve. A foot-piece, made of iron and padded, is con- 
nected with the screw, upon the inner side of the splint, 
and is moved nearer to, or farther from, the lower extre- 
mity of the latter by revolutions of the screw, so as to 
make the necessary extension, while the upper end of the 
splint fits into a little pouch upon the thigh-strap, thus ef- 
fecting the counter-extension : the foot-piece has two legs 
upon which it rests. In the application of this apparatus 
the foot is attached to the iron plate ; the upper end of the 
splint is inserted into the pocket of the thigh-belt, which 
has been previously passed around the upper part of the 
thigh and groin; a long pad protects the limb from contact 
with the outer splint, and equalizes the pressure from it ; 
then, after the reduction of the fracture, the inner and an- 
terior splints, well padded, are placed upon the thigh, and 
the whole is secured by means of several bands, as shown 
in the figure. (See fig. 66.) As much extension as the 
surgeon thinks necessary is made by turning the screw, 
thus drawing down the foot and with it, of course, the 
lower fragment of the broken femur. 

Fig. 66. 




Mr. Liston recommends the employment of a single 
straight splint of deal-board, long enough to extend from 
opposite the nipple to three or four inches beyond the foot ; 
near its upper end two holes are bored, and the lower ex- 



FRACTURES OF THE OS FEMOB.IS. 205 

tremity is notched, while just above the latter is a perfora- 
tion large enough to accommodate the malleolus ; the splint. 
is covered on its inner face by a cushion. The leg is ban- 
daged from the toes nearly to the seat of fracture, before 
the splint is applied : then the fracture is reduced, and the 
perineal band — made as for Desault's apparatus — is tied 
to the upper end of the splint, to which the whole limb and 
the side of the body are now confined by means of a roller, 
— several turns being passed around the foot and gaining 
support from the notches made in the lower end of the 
splint. Liston's Pract. Surg. (See fig. 67.) 

Fig. 67. 




Dr. Gibson, Professor of Surgery in the University of 
Pennsylvania, has introduced a modification of Hagedorn's 
apparatus, which he thus describes — (" Institutes and Prac- 
tice of Surgery," vol. i.) : — " This method consists in ex- 
tending the patient's limbs upon a mattrass, and confining 
both feet, by gaiters, or a handkerchief, to a footboard 
which is firmly supported upon the ends of two splints 
passed through mortices near its edges. These splints 
extend from the arm-pit, where they are padded like the 
head of a crutch, along each side of the body, thigh and 
leg, beyond the foot, and, being well stuffed on their inner 
surfaces to prevent irritation, are confined by six or eight 
broad tapes or bandages passed around the limbs, pelvis, 
chest, &c. (See fig. 68.) 

" The principle upon which extension and counter-exten- 

18 



200 



FRACTURES OF THE OS FEMORIS. 



sion are effected by this contrivance, will instantly be un- 
derstood. The sound limb being extended, serves as a 

Fig. 68. 




v*/ n 



splint to the broken one. Counter-extension then is made 
upon the acetabulum of the sound side, and extension upon 
the ankle of the injured limb, which, so long as the two 
feet are kept on the same level, cannot be shortened, pro- 
vided rotation of the pelvis be prevented. This purpose is 
answered by extending the splints to the arm-pits, and not 
with a view, as might be supposed, of producing counter- 
extension from these points. Finding that the patient, in 
the original machine of Hagedorn, (which consists of a 
single splint merely and a footboard, independently of 
leather straps, &c.) could incline the pelvis towards the 
affected side, and thereby shorten the limb, by causing the 
superior fragment to descend and overlap the inferior, the 
additional splint was added, and has been found to answer 
completely the end designed." 

During my residence in the Pennsylvania Hospital, I 
had the opportunity of testing the efficacy of this appara- 
tus, in two cases of fracture of the thigh, — one in a child, 
the other in an adult. In both instances, the result was as 
satisfactory as I have ever seen to follow the employment 
of any other method : I was led to make use of this appa- 
ratus, because the skin about the ankle and perineum of 
the child was so very tender, as to render the pressure 
upon these parts, from the gaiter and counter-extending 



FRACTURES OF THE OS FEMORIS. 207 

band of Desault's apparatus, insupportable, and, moreover, 
he was not sufficiently restrained by this last-mentioned 
apparatus ; — and because, in the instance of the man, the 
whole instep was much bruised by the same fall which 
caused the fracture of the thigh. The plan which I adopt- 
ed was the following: — A straight splint was first confined 
to the under surface of the sound limb, to prevent flexion 
of the knee; the splints were then placed on each side of 
the patient ; the sound foot was secured to the foot-board ; 
long pads protected the outer sides of the limbs from con- 
tact with the boards ; the fractured thigh was brought to 
the same length as the other, and the foot bandaged to 
the foot-board ; a firm junk-bag was now inserted between 
the limbs along their whole length, so that the injured limb 
should be supported at every point by the other, and seve- 
ral wide strips of muslin were made to enclose in their 
grasp each thigh, with its splint and the junk-bag ; finally, 
the splints above the pelvis were pressed against the pa- 
tient's sides, by means of muslin bands, and in the same 
manner lateral pressure was effected upon the whole ap- 
paratus. 

The management of this apparatus requires great atten- 
tion ; its confinement is very irksome to the patient, as it 
imprisons both limbs. It is particularly troublesome, when 
he has an evacuation of the bowels to effect, because he 
cannot assist himself, nor the attendant, with the sound leg ; 
when it is employed, therefore, a clinical frame, such as 
has been described, should be used instead of an ordinary 
fracture-bed, or the fracture-bed herein described, will be 
found serviceable and convenient. 

The same care as when the other splints are resorted to, 
is requisite, with regard to the prevention of injury to the 
parts of the integuments pressed upon, as the heel, ankles, 
hips, &c. 



208 FRACTURES OF THE OS FEMORIS. 

It is proper to mention that, in the man upon whom this 
apparatus of Dr. Gibson was tried, the fracture was at the 
lower third of the femur, and that the thigh was not a very 
muscular one. Whether a sufficient degree of extension 
can be accomplished by it, to maintain in coaptation the 
fragments of a thigh-bone, when the muscles of the limb 
are fully developed, and when the fracture is higher up, 
within the operation of the glutseus muscle, the author can- 
not affirm ; he has a sufficiently good opinion of the appa- 
ratus, however, to be induced to use it again. 

In fractures of the shaft occurring in young children, the 
method recommended bv Mr. Liston, as before described, 
with the addition of curved splints for the anterior, poste- 
rior, and inner surfaces of the thigh, is the most convenient 
and the best plan of treatment. The naturally slightly 
curved shape of the bone should be recollected, and this 
conformation should be secured by the proper use of com- 
presses. 

2. For fractures of the thigh at its upper extremity. 

The general principles of treatment in these cases are 
the same as when the shaft is broken ; but there are some 
anatomical and physiological peculiarities of the pelvic extre- 
mity of the os femoris, which require corresponding modifi- 
cations of treatment, when this part of the bone is ruptured. 

When the fracture occurs within the capsular ligament 
of the joint, bony union, according to the best authorities, 
is at least exceedingly improbable, if not impossible. (See 
Sir A. Cooper, Cruveilhicr, R. W. Smith, &c.) The acci- 
dent happens, moreover, for the most part, to persons ad- 
vanced in life and incapable of supporting long con- 
finement in bed in any one position. Concerning the 
treatment of these cases, Sir A. Cooper makes the following 
remarks: — "I would prefer a ligamentous union to the 
confinement and danger of bony union, in regard to the 



FRACTURES OF THE OS FEMORIS. 209 

health and life of the person, and, as I believe, to the sub- 
sequent use of the joint. Baffled in our various attempts 
to cure these cases, and finding the life of the patient occa- 
sionally sacrificed under the trials made to procure bony 
union, I should, if I sustained this accident in my own 
person, direct that a pillar should be placed under the limb 
throughout its length ; that another should be rolled up 
under the knee, and that the limb should be thus extended 
until the inflammation and pain had subsided. I should 
then daily rise and sit in a high chair, to prevent a degree 
of flexion which would be painful ; and, walking with 
crutches, bear gently on the foot at first, then, gradually 
more and more, until the ligament of union had become 
thickened, and the muscles increased in their power. A 
high-heeled shoe should be next worn, by which the halt 
would be much diminished. Our hospital patients, treated 
after this manner, are allowed in a few weeks to walk 
with crutches ; after a time a stick is substituted, and in a 
few months they are able to use the limb without any ad- 
ventitious support." (Sir A. Cooper, op. cit. p. 142.) 

When the solution of continuity has occurred partly 
within and partly without the capsular ligament, or through 
the great trochanter, the displacement is less, and it is more 
easily obviated. The limb should be kept in the extended 
position, by any of the methods which have been described, 
and the outer splint should be pretty firmly pressed against 
the trochanter and the side of the body by a circular band- 
age. The apparatus of Dr. Gibson would answer admi- 
rably in these cases. 

If the trochanter major be merely severed from the root 
of the neck, the axis of the bone not being involved, there 
is no shortening of the limb, and the treatment of the acci- 
dent is very simple. The patient should be kept upon his 
back, with the limb in the extended position, and rendered 

18* 



210 



FRACTURES OF THE OS FEMORIS. 



incapable of flexion at the knee and thigh by means of a 
well-padded splint, extending from above the tuberosity of 
the ischium to near the heel, and secured thus by rollers ; 
in addition, a broad band should be passed around the pel- 
vis, to compress the fragment of the trochanter upon its 
place. 

The annexed wood-cut illustrates a method pursued by 
Sir A. Cooper, in the treatment of this injury. The patient 
is lying upon a fracture-mattrass, to the foot of which is 
attached an upright support for the sole of the foot; a 

Fig. 69. 




broad band grasps the trochanter and presses it upon its 
natural seat. (See fig. 69.) 

3. For fractures at the lower extremity of the femur. 

The thigh-bone may be broken transversely just above 
the condyles, or obliquely, or the fracture may extend 
through the condyloid expansion into the joint. 

In the first case, there is oftentimes no displacement, or 
if the axis of the limb has been deranged, the fragments, 
after reduction, are easily retained in apposition by lateral 
compression and rest in the extended position. 

When, however, the fracture extends obliquely from be- 
hind forwards and downwards, as is usually its line of 
direction, or even from before backwards and downwards, 
the powerful muscles which descend from the pelvis act 



FRACTURES OF THE OS FEMORIS. 211 

with great energy upon the lower fragment, and draw it 
upwards, leaving the extremity of the upper fragment, in 
the first-mentioned variety, projecting anteriorly and pene- 
trating the rectus muscle, sometimes perforating the integu- 
ments even. The treatment of this injury consists in keep- 
ing up strong extension and counter-extension in the straight 
position, and in making as firm compression upon the frag- 
ments, when reduced, as the condition of the parts will 
allow, aided generally by evaporating lotions, leeching, 
&c, &c. After the lapse of three or four weeks, passive 
motion should be commenced cautiously and persisted in. 
(Sir A. Cooper.) 

Others advise that the limb should be secured upon the 
double inclined plane, the foot being well supported. They 
urge in favour of this position, that it relaxes the muscles 
which act so powerfully, upon the lower fragment, and thus 
renders sufficient a less degree of extension upon the in- 
flamed joint, while the mere pressure of the under surface 
of the limb upon the plane counteracts in a great measure 
the retraction of the lower fragment. 

A strong argument in favour of the straight position is 
that, if anchylosis should occur, the limb is in a much 
more desirable position than if the double inclined plane is 
employed. 

When one of the condyles is separated from its connex- 
ion with the lower portion of the femur, the extended posi- 
tion is certainly the most favourable one for the relief of 
the accident. A piece of pasteboard, large enough to in- 
close the posterior two-thirds of the joint, and notched 
along its margins to enable it to adapt itself better to the 
form of the part, should be softened in hot water and then 
moulded about the posterior face of the knee, and secured 
thus by means of a roller; Desault's apparatus, or a single 



212 FRACTURES OF THE 03 FEMORIS. 

straight splint for the under surface of the limb, will com- 
plete the necessary confining means. 

4. For compound fractures of the thigh, the same gene- 
ral principles of treatment exist as for the simple : the na- 
tural conformation and length of the limb should be pre- 
served, as far as possible. It must be borne in mind, 
however, that some degree of shortening will occur almost 
of necessity, in consequence of necrosis of the broken ex- 
tremities of the bone, and because, from the nature of the 
injury, the same degree of extension and of lateral com- 
pression cannot be maintained as in cases of simple frac- 
ture. 

The limb may be placed in the flexed position on a 
double inclined plane, or it may be extended by means of 
any of the different sorts of apparatus already described, 
or, finally, it may be placed in a long fracture-box, the 
sides of which are connected by hinges with the bottom 
piece, and extend, on the outer side to the axilla, and on 
the inner to the pelvis, the foot being secured to a perpen- 
dicular plane attached to the lower extremity of the bottom- 
piece. In this box, the limb may repose upon a bed of 
bran, which also affords the necessary lateral pressure 
when the sides of the box are closed. 

The bandage of Scultetus is, as in other compound frac- 
tures, the best compressing bandage, as it admits of re- 
moval and adjustment without disturbing the limb. The 
wound itself should be uncovered, excepting by a poultice, 
or some similar dressing, so that the matter may have free 
escape, and this should be aided by moderate pressure upon 
the thigh, above and below the wound, effected by the 
bandage, which should be made to act with particular care 
on any point or points beneath which the matter may be 
disposed to collect: if an abscess should form at any point 



FRACTURES OF THE PATELLA. 213 

remote from the wound, as happens in almost every com- 
pound fracture, it should be opened by the knife. 

The dressing for the wound must be varied to suit its 
appearance at different times. Great cleanliness of the 
parts, and also of the dressings, should be observed. 

The great length of time during which it is necessary to 
confine the patient to bed renders it advisable to resort to 
every expedient to prevent sloughing ; besides the frictions 
heretofore recommended in compound fractures, the posi- 
tion of the patient should be changed, from time to time, 
as far as may be consistent with the security of the limb ; 
the use of the inclined plane, for example, may be alter- 
nated with that of the straight splints. 

When the condition of the wound will allow of more 
direct compression being exercised about the seat of frac- 
ture, this means should be instituted as an aid in securing 
a proper shape to the thigh. For this purpose, strips of 
adhesive plaster, or of soap plaster, may be employed, — 
while the roller, or the bandage of Scultetus, cannot be 
used, — an interval being left between the strips, for the 
ready escape of the pus. 



SECTION II. 

ON THE APPARATUS AND DRESSINGS FOR FRACTURES OF THE 

PATELLA. 

The patella may be broken longitudinally, or trans- 
versely. 

1. Longitudinal fractures of this bone are attended with 
little or no displacement of the fragments, as a general 
rule; hence the probability of perfect reunion by bony 
matter is great, and the treatment is very simple. The leg 



214 FRACTURES OF THE PATELLA. 

should be extended upon the thigh, and the thigh flexed to 
a moderate degree upon the pelvis, while a roller is passed 
around the limb, from the toes to the upper part of the 
thigh, being made to exercise considerable lateral pressure 
upon the fragments of the patella, by means of compresses 
placed at each side of the bone. The limb should be laid 
on a simple inclined plane, and, for the sake of greater 
security, a splint should be bound to its under surface. The 
application of these retentive means should be preceded, if 
there be much inflammation about the joint, by leeching ; 
and after the bandage is applied, cold lotions may be em- 
ployed, if required. 

2. When the fracture has assumed a transverse direction, 
a considerable degree of separation of the fragments is 
unavoidable, the retraction of the upper portion varying 
from one to three or four inches, according to the power 
of the extensor muscles which are connected with the 
base of the patella, and to the position in which the limb 
has remained after the injury. 

A variety of mechanical contrivances have been resorted 
to, to remedy the effects of this accident and to maintain 
the fragments in apposition. The union is always by liga- 
ment ; and it must be borne in mind by the surgeon that, 
although a very good apposition may have been gained 
and retained during the treatment, the ligament of union 
almost invariably becomes elongated after the patient com- 
mences to use the limb, even when a splint has been ban- 
daged to its under surface and worn thus for a long time 
after confinement to bed has ceased. This fact should 
always be impressed upon the patient and his friends, as 
otherwise the surgeon may suffer in reputation. 

The treatment recommended by Sir A. Cooper is, that 
the limb be lightly bandaged to a straight splint placed all 
along the under surface of the limb, the knee being left en- 



FRACTURES OF THE PATELLA. 



215 



tirely uncovered; that the extensor muscles of the leg be 
relaxed by elevating the limb upon an inclined plane, while 
the trunk is flexed upon the pelvis, and that local antiphlo- 
gistic remedies be applied upon the joint, until inflammation 
shall have ceased. Then " a roller is applied from the foot 
to the knee, to prevent the swelling of the leg, and the 
upper portion of the patella is pressed downwards towards 
the lower, as far as it can be without violence, so as to 
produce the approximation of the fragments. Rollers are 
applied above and below the joint, confining a piece of 
broad tape next the skin on each side, which crosses the 
rollers at right angles ; these tapes are next bent down and 
tied over the rollers, so as to bring the latter near to each 
other, and thus to keep down the upper portion of bone. 
Sometimes, instead of the tape on each side, a broad piece 
of linen is bent over the rollers on the fore part of the joint, 
and is there confined, so as to approximate the portions of 
bone and to bind down the upper fragment of the patella, 
that its lower broken edge may not turn forwards." (Op. 
cit. p. 205.) (See fig. 70.) 

Fig. 70. 




Another method recommended by the same high autho- 
rity is the following : — A leathern strap may be buckled 
around the lower part of the thigh, above the broken and 
retracted fragment of bone ; from this circular band another 
strap should be passed along the side of the leg across the 



216 FRACTURES OF THE PATELLA. 

sole of the foot, the leg being extended and the foot flexed 
as much as possible. This strap is then carried up along the 
other side of the leg, and buckled to that which has been 
fixed around the thigh ; it may be confined to the foot by a 
tape tied to it, and to the leg, at any part, in the same 
manner. This is a very convenient bandage for the 
fractured patella, and for the patella dislocated upwards by 
the laceration of its ligament. A roller is to be applied 
around the leg. (Op. cit. p. 205.) (See fig. 71.) 

Fig. 71. 




M. Desault directed that the limb should be held in the 
position above advised, by an assistant, and a roller passed 
around the leg from the toes to the knee, confining on the 
front of the leg a band about two inches wide and of the 
length of the limb ; then that two longitudinal slits be made in 
this band, opposite the patella, through which the surgeon 
passes two fingers and approximates the fragments : that a 
compress be applied just above the upper fragment and re- 
tained there by several turns of the roller passing around 
the knee in the form of the figure 8 ; the bandage now 
should cover the thigh, a padded splint, as long as the 
limb, should be confined upon its under surface, and the 
whole supported on an inclined plane. 

M. Gerdy employs an invaginated bandage, such as is 
used in the approximation of the lips of transverse wounds. 
(See chap, on Wounds.) The leg, as high as the knee, is 
enveloped by a roller, which also confines upon the front of 



FRACTURES OF THE PATELLA. 217 

the leg the tailed portion of the bandage, the slit portion 
being secured upon the front of the thigh by a second roller; 
then, having placed a compress above the upper fragment, 
and another below the inferior, pass the tails of the ban- 
dage through the slits, and approximate the fragments ; this 
having been effected, lay the portions of the bandage 
smoothly along the limb, and secure them by turns of a 
roller. 

Mr. Amesbury has invented an apparatus consisting of 
two wide leathern pads, to be placed one on the anterior 
face of the thigh above the knee, the other on the leg below 
the knee, and attached to each other by straps and buckles. 
In order to compress the extensor muscles of the leg, and 
at the same time to avoid unnecessary constriction of the 
limb, these pads are secured by means of straps and 
buckles, to a splint placed on the under surface of the mem- 
ber, with a foot-board attached, and made sufficiently wide, 
opposite the knee, to project a little beyond it upon each 
side. The upper pad, and with it the corresponding frag- 
ment of the patella, is made to approximate the lower by 
means of a strap, which passes from the lower edge of the 
upper pad, along the side of the leg, and across the foot- 
board, to ascend on the other side of the leg and be buckled 
to the pad. (Amesbury, vol. ii. p. 492, &c.) 

Mr. Lonsdale has contrived an instrument, which he has 
found very efficacious in the treatment of this fracture. It 
consists of a splint upon which the limb reposes, and to which 
a foot-piece is attached in such a way as to be movable up 
and down, to accommodate the splint to limbs of different 
lengths; to the under surface of this splint two vertical iron 
bars are connected, A B, (see fig. 72,) at about its centre, each 
one supporting a horizontal arm bent at right angles, G G ; 
these horizontal pieces slide upon the upright staffs, but can 
be arrested at any point by the screws, CD; from these arms 

19 



218 



FRACTURES OF THE PATELLA. 



Fig. 72. 




depend other vertical rods, movable upon the former, and, 
like them, fixable by similar screws, E ; finally, to the lower 
end of each of these second perpendicular rods, an iron 
plate, F, F, of a horse-shoe form, is attached, by means 
of a hinge-joint. In the application of this apparatus, the 
splint should be well padded, and the foot and leg secured 
to it by a roller, a bandage having been first passed around 
these parts ; then the surgeon places the fragments of 
the patella in juxtaposition, the muscles being relaxed as 
before directed, and applies the upper horse- shoe plate to 
the upper part of the thigh, a soft pad intervening, just 
above the superior fragment, — not touching the patella 
itself, while the other plate is applied just below the inferior 
fragment ; the plates are secured in these relations by 
means of the screws, and a roller is passed around the 
thigh and the upper part of the splint. The limb is retained 
during the treatment in the same position as in the other 
modes already described. 

Mr. Lonsdale states the advantages of this apparatus to 
be, that it may be applied immediately after the fracture 
occurs, that it produces no constriction of the limb, and 
that it leaves the injured part exposed to the inspection of 
the surgeon during the whole course of the treatment, and 
allows of the application of antiphlogistic remedies ; he has 



FRACTURES OF THE PATELLA. 219 

found it to answer the purpose for which it was intended, 
in a very satisfactory degree. (Op. cit. p. 427, &c.) 

The apparatus of Boyer, of Dorsey, Mog ridge, and 
others, offer no particular advantages above those which 
have been described. 

After the limb has been thus confined for six or eight 
weeks, passive motion should be commenced and practised 
cautiously but diligently; in the course of two weeks longer 
time, the patient may be permitted to bear moderately upon 
the foot in walking, a splint being bound to the under sur- 
face of the limb : he should step on the sole of the foot 
flatly, and not on the toe ; the splint should be worn thus, 
for a few weeks. 

3. Rupture of the tendon, and of the ligament of the 
patella should be treated in the same manner as if the bone 
itself were broken. 

4. Compound fractures of the patella require the same 
general principles of treatment as the simple forms. But 
in addition to the injury done to the bone, that which is in- 
flicted upon the soft parts and on the joint demands atten- 
tion, and modifies the treatment. The indications are, to 
close the wound immediately, in the hope that it will heal 
without being accompanied by violent constitutional dis- 
turbance, and to retain the fragments of the patella in as 
close apposition as the condition of the parts will permit. 
The limb must be placed upon a splint in the same position 
as directed for simple fracture, the body being well sup- 
ported in the flexed position on the pelvis, by pillows ar- 
ranged behind the back. The lips of the wound, after all 
foreign matter has been removed from the opened joint, 
should be drawn together by strips of adhesive plaster, 
which strips may be so applied as to draw down the upper 
fragment of the patella, and to retain it in apposition with 
the lower : then a piece of lint should be dipped in the blood 



220 FRACTURES OF THE BONES OF THE LEG. 

which flows from the part, or in some adhesive and gluti- 
nous fluid, and laid upon the wound, where it should be 
retained by a light bandage ; all pressure being avoided 
upon the joint itself, the muscles of the thigh may be mo- 
derately compressed by a roller, the same which confines 
the splint upon the limb. Thus arranged, the dressing 
should not be disturbed so long as no unpleasant symptom 
arises ; such as severe inflammation, free suppuration, &c. 
In a case recorded by Sir A. Cooper (op. cit., p. 210, 11), 
the first applications were not removed until a month after 
the accident, when the wound was found nearly healed : 
the patient in this case recovered with a perfectly useful 
limb. 

The author treated in this manner, at the hospital, a case 
of compound fracture of the patella, produced by a kick 
from a horse, in which a similarly happy cure followed. 
If, how r ever, violent inflammation follows the injury, with 
profuse discharge and much constitutional suffering, the 
primary dressing must be at once removed, and antiphlo- 
gistic remedies resorted to, — as local and general depletion, 
poultices, or water-dressings, &c, &c. Passive motion 
should be cautiously instituted as soon as circumstances 
will admit of it. The introduction of sutures should be 
avoided as much as possible ; if employed, care should be 
exercised not to include the ligament in the suture. (Sir A. 
Cooper, op. cit-, case 137, p. 210.) 

SECTION III. 

FOR FRACTURES OF THE BONES OF THE LEG. 

Like those of the forearm, the two bones of the leg may 
be broken at the same time, or each may be fractured sepa- 
rately. 



FRACTURES OF THE BONES OF THE LEG. 221 

1. When both the tibia and fibula are broken, the maxi- 
mum degree of displacement is produced, partly by the 
violence causing the fracture, and partly by the action of 
the powerful muscles situated about the leg. The line of 
fracture is generally oblique, in almost any direction, and 
this direction influences the course of displacement which 
the lower fragment assumes. When the solution of con- 
tinuity of the fibres of the bone is in a transverse direction, 
there is often no shortening of the leg, but merely a lateral 
derangement ; when, however, the fracture is oblique, there 
is both lateral deformity and shortening ; in the former in- 
jury, the fragments are easily retained in apposition, after 
reduction, by rest alone ; in the latter, a continued con- 
fining apparatuses necessary to counteract the disposition 
on the part of the muscles to contract and to draw upwards 
the inferior portion of the bones. Generally, a moderate 
degree of mechanical force, with the limb in the straight 
position, suffices for the successful treatment of simple 
fractures of the leg; there are instances, however, in which, 
from the powerful action of the muscles and the direction 
of the line of fracture, such deformity is produced that it 
becomes desirable to take advantage of the effect of posi- 
tion to aid the treatment, as in fractures of the thigh. 

The simplest plan of treatment by mechanical means, 
consists in the employment of the "junks;" — these are ge- 
nerally made of pieces of wood, or of bags of straw, or 
chaff, rolled firmly in a splint cloth, and long enough to 
extend from the lower third of the thigh to below the ankle, 
on each side of the limb. In the application of this appa- 
ratus, the junks thus rolled are glided underneath the leg 
upon a pillow, which supports the whole leg and the heel; 
the fracture is reduced, and the mechanical supports 
brought in contact on each side with the knee and the 
ankle, all the intermediate parts of the leg being likewise 

19* 



222 FRACTURES OF THE BONES OF THE LEG. 

apposed to the lateral supports, either directly, or through 
the intervention of compresses of cotton, or tow ; the whole 
is secured thus by strips of muslin passed around the junks. 

This apparatus leaves the anterior face of the leg ex- 
posed to th§ examination of the surgeon and to the action 
of local applications, while at the same time it exerts a 
sufficiently powerful lateral compression upon the leg, to 
retain in apposition the fragments of the bones, in all cases 
of transverse fracture, and in many, or most, of the oblique. 
It does not, however, offer so great a degree of security 
against sudden, or accidental, movements of the limb, as 
another apparatus, which is almost as simple as itself, — 
the fracture-box, of which mention will be made directly. 

Many different kinds of splints have been contrived at 
various times, and by different surgeons, for the treatment 
of these injuries. The best have all sought to give support 
to the inferior surface of the leg and the foot, and also to 
exert more or less lateral compression. Thus the splints 
of Mr. Neville, highly recommended by Mr. Lonsdale and 
others, consist of a light iron piece padded, for the inferior 
face of the leg, extending from the lower part of the thigh 
to the foot, at which point it curves upwards, to form a sup- 
port for the sole of the latter, — and of two lateral splints, 
of the same length as the other, and also padded, and 
secured to the sides of the foot-piece by a mortice-and- 
pinion joint; circular strips of muslin complete the ap- 
paratus. 

The fracture-box, however, combines all the advantages 
of these with many others which these do not possess, as 
greater simplicity of construction, and in consisting of but 
a single piece, as it were, by which greater solidity is 
gained. It is composed of a horizontal plane of board ex- 
tending from a little above the knee to the sole of the foot, 
where a piece, rather longer than the foot, and of the same 



FRACTURES OF THE BONES OF THE LEG. 



223 




width as the other plane, is firmly secured to it at right 
angles: side-pieces, also made of wood, six or seven inches 
wide, and of the same length as the bottom-piece, are con- 
nected with the latter by ■ _ 

tig. 15. 

hinges. (Fig. 73.) To ap- 
ply this apparatus to the 
treatment of fractures of 
the leg, open the sides of 
the box, and place a pil- 
low upon it, soft enough 
to adapt itself well to the 

inequalities of the leg ; then, having reduced the fracture, 
secure the foot to the foot-board by a strip of bandage, 
and close the sides of the box, more or less tightly, ac- 
cording to the condition of the limb and the degree of 
pressure requisite to retain the fragments of the bones in 
apposition; the sides are thus secured by strips of mus- 
lin. If the pillow alone is insufficient to exert the requi- 
site pressure, compresses should be used in addition, and 
these should be so placed as that 
the pressure may bear upon those 
particular points where they are 
most needed. Thus the proper 
shape of the limb may be easily 
preserved, being made more or 
less curved by the action of the 
pillow and compresses. In this 
manner, some of the most marked 
deformities may be obviated. 
Thus, for example, in treating 
the fracture of which the annex- 
ed drawing from Fergusson's 
Practical Surgery (Am. ed. p. 
339) illustrates the appearance, 
the leg should be placed in the 



Fig. 74. 




224 FRACTURES OF THE BONES OF THE LEG. 

fracture-box, as above directed, and a compress be applied 
upon the tibial side of the limb, just above the prominence 
of bone, while another is laid on the fibular side, a little be- 
low the seat of fracture ; the compression exercised upon 
these points, when the sides of the box are closed, will 
suffice to restore the leg to its proper shape, and to retain 
the fragments in complete apposition. (Fig. 74.) 

The shape of the sound leg should be compared daily 
with that of the broken one, and any deviation from the 
proper line in the latter should be rectified in the manner 
pointed out. The foot should be kept upright against the 
foot-board, the heel supported by the pillow, and an addi- 
tional pad if necessary. If there be any signs of excoria- 
tion or sloughing on the heel, or malleoli, pressure should 
be immediately removed from these points, and brought to 
bear upon others, and the surface protected by simple 
cerate, or stimulated by frictions with spirits of camphor, 
soap liniment, &c. &c. Care is requisite lest the foot fall 
below its proper line, as compared with that of the sound 
leg : to obviate this liability to displacement of the lower 
fragment, a pad of cotton should be placed under the heel. 

The advantages of the fracture-box are evident : it is 
perfectly secure ; very simple in its construction ; fully ca- 
pable of retaining in place the fragments of the bones, in 
the vast majority of fractures of the leg, and it leaves the 
limb always open to inspection, and for the application of 
local remedies. In very many cases of this fracture, it is 
necessary or advisable to employ sedative lotions ; one of 
the best of these is the solution of the acetate of lead ; an 
objection to this, however, is that in many persons it irri- 
tates the skin too much, and in all it is apt to leave a depo- 
sition of the salt upon the surface, which is sometimes the 
source of irritation. When any liquid application is made, 
or any other dressing which may soil the pillow, a piece 



FRACTURES OP THE BONES OP THE LEG. 225 

of soft oilcloth should be spread upon the latter, before the 
leg is placed in the box. 

Very often indeed, in fractures of the leg, the skin will 
be found, in the course of a day or two after the accident, 
covered with small vesicles particularly near the seat of 
the injury. This appearance, in persons of ordinarily good 
constitutions, is a matter of no importance, being indica- 
tive merely of a certain degree of irritation of the skin, 
which soon subsides under the application of cold water, 
and often it disappears if no local means are used ; but the 
same appearance in persons of bad constitution, especially 
in habitual drunkards, is frequently the precursor of erysi- 
pelas or mortification, and should be carefully watched. 

The most troublesome simple fracture of the leg is that 
in which the tibia has been broken obliquely, the line of 
fracture extending downwards and forwards. Here the 
powerful muscles of the posterior surface of the leg draw 
the inferior fragment upwards, leaving the sharp extremity 
of the upper part of the bone projecting against the skin, 
and threatening to produce ulceration of the integuments 
at this point. Where this action of the muscles is but 
slight, the fracture-box may be employed, care being had 
that the inferior fragment, at the seat of the injury, is well 
supported by a compress placed beneath it. In other in- 
stances it will be necessary to adopt some plan of treatment 
which shall oppose the muscular contraction by direct ex- 
tension and counter-extension, or which shall produce the 
same effect by simply relaxing the muscles in question. If 
the first mode be resorted to, the splints advised by Dr. 
Hutchinson, of this city, may be employed. They are two 
in number, extending from the knee to some inches beyond 
the foot; the upper end of each splint has perforations 
made in it, for the attachment of the counter-extending 
bands, and at the lower extremity of each is a mortise, 



226 FRACTURES OF THE BOXES OF THE LEG. 

through which a bar is passed. The leg is laid upon a 
pillow, upon which a bandage of Scultetus is arranged ; 
tapes are secured upon each side of the leg, just below the 
knee, by means of a roller, and a gaiter, or a cravat, is 
fastened to the foot and ankle ; then the fracture having 
been reduced, the leg is supported by an assistant, and the 
bandage of Scultetus folded upon it ; the splints are now 
placed by the sides of the leg, pads intervening, the counter- 
extending bands are fastened to the upper ends of the 
splints, and the extending to the transverse bar passed 
through the mortises at the lower extremities, and the 
whole apparatus thus secured by strips of muslin tied 
around it. The long thigh splints of Desault may also be 
used for the same fracture, instead of the shorter splints of 
Hutchinson. 

If the treatment by position is decided upon, the ordinary 
double inclined plane may be used, as advised in fractures 
of the thigh, a foot-board being attached to the lower plane, 
so that the foot may be well supported in the proper posi- 
tion. Or the fracture-box just described may be placed 
upon a double inclined plane, and the leg properly arranged 
in it. The last will probably be found to be the best plan, 
as the leg can thus be more securely disposed of, than when 
the plane alone is used ; in the latter case lateral splints 
should be employed to steady the leg, and to make the ne- 
cessary compression upon the sides. By thus flexing the 
knee, the muscles which draw up the lower fragment of 
the tibia are rendered almost inoperative, and the apposi- 
tion of the two portions of bone is secured very readily ; 
a bandage of Scultetus may be advantageously employed 
for a few days, around the seat of fracture, but it should 
be removed daily and the condition of the leg be inspected. 

Mr. Liston has devised a double inclined plane for the 
treatment of fractures of the leg, which he thinks superior 



FRACTURES OF THE BONES OF THE LEG. 227 

to any other ; it is also well recommended by Fergusson 
and many other English surgeons. " It consists of a thigh 
and leg-piece of sheet iron, and a foot-board of wood ; the 
former are joined to each other by a couple of hooks and 
a screw, which is so placed that the two plates can be set 
to any angle at which it may be desirable to bend the knee, 
and the foot-board is so affixed that it maybe slid upwards 
or downwards, to suit the length of the limb, and fastened 
by a side screw in any position that may be advisable. At 
the lower end of the machine, there is a cross-plate of iron, 
which is so attached that, in the event of the foot being 
raised or depressed, it will always rest flatwise on the 
mattrass, or on a board placed at the foot of the bed for 
the purpose of supporting it." (Fig. 75.) The limb is to 
be laid upon the splint, which has been well padded ; cot- 
ton or tow should be used to adapt the surfaces to each 
other, and to aid in making pressure upon particular points, 
and a roller is then to be passed around the limb and the 
splint. The angle of the apparatus may be varied as may 
be judged proper. 

Fig. 75. 




2. If the tibia alone is broken, the displacement cannot be 
very great ; the accident may be treated by any of the methods 
above spoken of, or a splint of pasteboard, previously mould- 
ed to the leg, may be applied upon the inner or inferior sur- 
face, and confined by a roller, or by the starched bandage, 
and the limb kept at rest upon a pillow. But even in simple 



228 



FRACTURES OF THE BONES OF THE LEO. 



Fig. 76. 



fracture of the tibia, it is safer to make use of the fracture- 
box, at least during the first week or ten days : the same 
precautions and attentions should be used during the treat- 
ment, as in the cases above considered, though they are 
less necessary. 

3. In fracture of the fibula only, when the injury has 
occurred above the lower three inches of the bone, nothing 
more than a simple lateral or angular displacement ensues, 
and the treatment demanded is the same as has been just 
advised for simple fracture of the tibia. But when the 
fracture has occurred at the lower two or three inches of 
the bone, constituting what is called " Pott's fracture," a 
great lateral displacement is produced, rendered more re- 
markable by rupture of the internal lateral ligament of the 
ankle, which in the majority of cases is caused simultane- 
ously with the fracture of the fibula. The 
annexed drawing, taken from Mr. Lonsdale's 
book, p. 522, exhibits the point at which the 
bone is usually broken, the rupture of the in- 
ternal ligament, and the peculiar deformity; 
(fig. 76,) and it shows the applicability of the 
mode of treatment recommended by Dupuy- 
tren. This method consists in the applica- 
tion to the tibial side of the leg of a splint 
and cushion of peculiar conformation. " The 
cushion, made of cloth and filled two-thirds 
with chaff, should be two feet and a half long, 
four or five inches wide, and three or four 
inches thick. The splint, from eighteen to 
twenty inches long, two and a half inches 
wide, and three or four lines thick, should be made of firm 
and slightly flexible wood. Lastly, the two bandages used 
should be each four or five yards in length, and two and 
a half inches wide. The cushion, folded upon itself in the 




FRACTURES OF THE BONES OF THE LEG. 



229 



Fig. 77. 



form of a wedge, is applied to the inner side of the frac- 
tured limb, upon the tibia, its base directed downwards, 
being laid upon the internal malleolus, and not passing 
below it, its apex reposing upon the internal condyle of 
the femur. The splint laid upon this cushion should extend 
beyond it, from four to six inches, and beyond the inner 
edge of the foot three or four inches." One of the rollers 
is used to confine the upper part of the splint and cushion 
upon the leg, while the other draws the foot 
towards the inferior end of the splint, " being 
directed successively from the latter over the 
upper surface of the foot, upon its outer side, 
under the sole of the foot, upon the splint; 
then from this upon the instep and under the 
heel, to return again to the splint, and to be 
continued in the same manner until all the 
bandage is used. The foot is brought into 
such a state of adduction, that its external 
margin becomes inferior, the sole of the foot 
being directed inwards, and its internal edge 
upwards." (Dupuytren, Lecons Orales, torn. i. 
p. 226.) The annexed figure illustrates the ap- 
plication of this splint. (Fig. 77.) 

Most cases of this fracture may be treated with com- 
plete success by the fracture-box. A reference to fig. 76 
will show the points upon which compresses should be 
placed, to rectify the deformity; viz. one upon the external 
malleolus, and the other upon the side of the tibia, just 
above the extremity of the bone ; then, when the sides of 
the box are brought up against the foot-board, the foot will 
be forced into its proper position, and thus retained. The 
advantages of Dupuytren's splint are, that the patient need 
not be confined to bed for any length of time, but may 
walk with his broken leg supported in a sling depending 

20 




230 FRACTURES OF THE BONES OF THE LEG. 

from the neck, or he may be allowed to travel, if his cir- 
cumstances require it, provided care be taken to support 
the member. 

The apparatus, whichever it be that is used in the treat- 
ment of fractures of the leg, may be suspended from the 
ceiling, or from the top of the bed, according to the plan 
recommended by Sauter and Mayor : this method has been 
already sufficiently explained, to enable the surgeon to 
adapt it to the fractures in question. It is difficult, how- 
ever, to see the particular advantages which would result 
from such a modification of the stationary apparatus. 

When fractures of the leg occur in persons who are at 
the same time affected with mania-a-potu, perhaps the most 
secure bandage will be the starch bandage with splints of 
pasteboard. 

4. Compound fractures of the leg must be treated after 
the general principles recommended in similar injuries of 
the arm and thigh. The bran-dressing, first resorted to by 
Dr. J. R. Barton, of this city, and to which allusion has 
been before made in these pages, is particularly well 
adapted to the treatment of compound fractures of the leg. 
In such cases, the bran is used as a substitute for the pillow 
employed in simple fractures. The fracture-box has a suf- 
ficient quantity of the bran laid upon the bottom of it, to 
afford a soft resting-place for the leg ; the leg is placed upon 
it, the form of the limb adjusted as well as possible, the 
foot is properly attached to the foot-board ; then the sides 
of the box are closed, and the box itself filled with bran. 
The requisite degree of lateral pressure can generally be 
gained by packing the bran pretty firmly opposite particu- 
lar parts of the leg ; and in addition, a few strips of ad- 
hesive plaster may be drawn around the limb at the point 
of fracture, without closing the wound entirely, or mate- 
rially interfering with the ready exit of the pus. Thus the 



FRACTURES OF THE BONES OF THE LEG. 231 

leg is imbedded in the midst of a substance which absorbs 
at once the discharged matters; which diminishes the un- 
pleasant foetor, by secluding the pus from the action of the 
air ; which is itself clean, light, and cool, and which is 
easily renewed. It will be found, moreover, to be the most 
effectual mode of preventing the deposition of the ova of 
flies and other insects which, in our warm summers, be- 
come developed in the wound and are the source of great 
inconvenience and annoyance. 

The disposition to the formation of abscesses at points 
remote from the wound is often met with in compound 
fractures of the leg. When formed, they should be opened 
as soon as possible, and the matter confined between the 
point of incision and the original wound by a few strips of 
the bandage of Scultetus laid above the seat of abscess, or 
below it, as the case may be. 

Very generally in these injuries, the wound is on the 
anterior face of the leg ; but it sometimes happens that the 
integuments are ruptured on the posterior face, or on one 
side ; in the latter cases the fracture-box may still be em- 
ployed, care being had that too great pressure is not exer- 
cised upon the wound itself. But when the solution of 
continuity exists on the posterior part of the leg, some ap- 
paratus must be resorted to which will allow the limb to 
repose upon its side. For this purpose, a wooden splint may 
be used, grooved to receive the leg, and terminating below 
in a foot-piece. The patient should repose upon his side, the 
thigh and leg flexed and resting upon pillows. The broken 
leg should be placed in the splint, (on the side opposite to the 
wound, so as to leave the latter exposed,) and confined to 
the splint at the knee and at the foot, by means of rollers. 
Little force will be required, generally, to retain the frag- 
ments in apposition, the flexed position in which the whole 



232 FRACTURES OF THE BONES OF THE FOOT. 

limb is placed itself relaxing the muscles : but compression 
may be resorted to, if necessary, by strips of adhesive plas- 
ter, or of the bandage of Scultetus. laid above and below 
the wound, while this is covered with a poultice, or some 
other suitable dressing; the pillows should be protected by 
a piece of oil-cloth, upon which bran, cotton, or any ab- 
sorbing material, should be placed, to catch the discharges 
from the wound. 



SECTION IV. 

FOR FRACTURES OF THE EONES OF THE FOOT. 

Very little displacement accompanies simple fractures of 
the bones of the foot, as a general rule, and therefore the 
treatment is very simple. The foot should be kept at rest, 
with a splint of wood, or of pasteboard, bound to its sole, 
and a broad compress applied on the superior surface. Or 
an equally good plan consists in placing the leg in a frac- 
ture-box, with the sole of the foot confined to the foot-board, 
by a broad band, which leaves the dorsum of the foot suf- 
ficiently exposed to the action of local antiphlogistic appli- 
cations. 

When the posterior extremity of the os calcis is broken, 
there need not be much displacement, if, as is generally the 
case, the strong plantar ligaments connected with this part 
of the bone remain unruptured. Under other circum- 
stances, however, the fragment is more or less drawn from 
its natural position, by the contraction of the gastrocne- 
mius and soleus muscles, and the treatment employed must 
be adapted to counteract their influence. For this purpose 
the apparatus recommended by Mr. Lonsdale is very sim- 
ple and effect ual. It consists of a foot-piece of wood, to 
the extremity of which the end of a slipper is attached, for 



FRACTURES OF THE BONES OF THE FOOT. 



233 



the reception of the toes. The foot-board should be rather 
shorter than the sole, so as to extend from the toes not 
quite to the heel ; to its under surface a ring is attached. 
A pad, or compress, is placed upon the extremity of the os 
calcis, (the fragment having been restored to its proper 
position,) and confined thus by a few turns of a roller; 
then a strap of leather, or a band of webbing, is passed 
through the ring of the foot-board, upwards over the heel 
and the pad, over the calf of the leg to the lower third of 
the thigh, where it is reflected upon itself, — the knee being 
flexed, and the foot extended, — and confined to the surface 
by turns of a roller, (fig. 78.) 



Fig. 78. 



Fig. 79. 





This same apparatus will answer for the treatment of 

20* 



234 FRACTURES OF THE BONES OF THE FOOT. 

rupture of the tendo Achillis, with the addition of a roller 
applied carefully from the toes to the knee. The same 
effect may be gained by a method even more simple than 
this, as follows : Encircle the lower part of the thigh with 
a strap, or a roller tightly applied, and connect this, by 
means of a strip of muslin, to the heel of a slipper placed 
upon the foot, — the leg being flexed upon the thigh ; enve- 
lope the foot and leg in a roller. The annexed drawing, 
from Druitt, exhibits this plan of treatment, (fig. 79.) 

In compound fractures of the bones, the foot should be 
kept in the same position as in- case of simple fracture, 
with a poultice, or other proper dressing applied over the 
part. 



PART IV. 

ON THE MECHANICAL MEANS EMPLOYED IN THE 
TREATMENT OF DISLOCATIONS. 

A dislocation, or luxation, is defined by Sir Astley 
Cooper to be, " a displacement of the articulating portion 
of a bone from the surface on which it was naturally re- 
ceived." This faulty position is maintained, and the re- 
duction of the dislocation opposed, by a combination of 
causes ; sometimes, and partially, by the conformation of 
the bony surface on which the displaced member rests, as 
the prominent margin of the acetabulum, in dislocations of 
the hip; — occasionally, to a certain extent, by the situation 
and condition of the ligaments about the joint ; — but chiefly 
and in every case, by the powerful clonic and tonic action 
of the muscles. These obstacles cannot be overcome 
without resort, on the part of the surgeon, to physical 
force. 

It does not fall within the province of this volume to dis- 
cuss'the pathology of this class of accidents; its limits and 
its legitimate intention permit only a description of the 
mechanical means employed in their treatment. The sub- 
ject naturally divides itself into two branches: 1st, the 
means of reducing the dislocation, or of restoring the dis- 
placed bone to its natural situation; 2d, the mode of re- 
taining the bone in place, until the necessary reparation of 
the injury done to the tissues shall have become perfected. 

Luxations are replaced by means of muscular force 



236 DISLOCATIONS. 

acting directly upon the two bones involved, or indirectly 
through the intervention of some mechanical apparatus, the 
object of which is to increase the power of the muscles, and 
to render it more uniform and more equable in its operation. 
The force thus excited must act in two opposite directions: 
one, — the extending, — upon the movable part, that which 
has been displaced ; while the counter-extension is exer- 
cised on the opposite part, serving merely to fix and steady 
it. The points upon which these forces operate vary in 
different dislocations : generally, the muscles which directly 
surround the joint, and which, if they are excited to con- 
traction by any cause, may interfere w T ith the execution of 
the object in view, should not be compressed by the ex- 
tending and counter-extending powers, unless from motives 
of convenience and expediency. 

When the dislocation has been reduced, there is, gene- 
rally, but little disposition to redisplacement : it is necessary 
merely to keep the muscles surrounding the joint, and the 
joint itself, in a state of repose, for a certain time. This 
object is secured by the application of retentive bandages 
and splints. 

The special dislocations w T ill be briefly considered, w r ith 
particular reference to the mode in which the various me- 
chanical means alluded to are applied. 



CHAPTER I. 

DISLOCATIONS OF THE BONES OF THE HEAD AND 

TRUNK. 

SECTION I. 

DISLOCATION OF THE LOWER JAW. 



Reduction. — In this accident the articular surface of one, 
or of both, of the condyloid processes of the inferior maxilla 
rests upon the base of the zygomatic process, being thrown 

forwards out of the 

, -j • Fig. 80. 

glenoid cavity, as is s 

represented in the an- / /^v i 
nexed woodcut, (fig. 
80.) To remedy the 
deformity, the sur- 
geon places his 
thumbs, well wrapped 
around with muslin, 
to protect them from 
injury, between the 
posterior molar teeth 
on each side of the 

jaw, grasping the base of the bone on each side with his 
fingers; then, the patient's head being well supported 
against the back of a chair, or by the hands of an assistant, 
the surgeon presses his thumbs strongly downwards upon 




238 DISLOCATIONS OF THE CLAVICLE. 

the molar teeth, while with his fingers he forces the chin 
upwards ; thus the condyloid processes are removed from 
their false position, and by the contraction of the muscles 
connected with the posterior part of the bone, are drawn 
into the glenoid cavities. 

The succeeding treatment consists in the application of 
a simple retentive bandage, as that of Barton, or off Gibson, 
(see Fractures of Lower Jaw,) and in nourishing the 
patient for the following two or three weeks with liquid 
food. 

SECTION II. 

DISLOCATIONS OP THE BONES OF THE TRUNK. 

If the vertebrae, the ribs, or the bones of the pelvis chance 
to be separated from their articular connexions, the acci- 
dent is generally accompanied by other serious, if not 
fatal, injuries to the organs contained in the thoracic, abdo- 
minal and pelvic cavities. The surgeon can do little or 
nothing towards replacing the dislocated bones. Perfect 
rest should be enjoined, with the use of such local and 
general antiphlogistic remedies as may be requisite. The 
simple body-bandage for the chest, or pelvis, will effect all 
that can be expected of any mechanical contrivance ; or 
the bandages shown in figures 27, 30 and 69 may be em- 
ployed, according to the region injured. 

SECTION III. 

DISLOCATIONS OF THE CLAVICLE. 

Either articular extremity of the clavicle may be luxated : 
the modes of effecting reduction are very similar in all 
varieties of the accident. The patient being seated, the 
surgeon takes a position behind him, grasping each shoulder, 



DISLOCATIONS OF THE CLAVICLE. 



239 



and having one knee placed against the spine between the 
shoulders, so as to steady the patient, while he draws the 
shoulders backwards, and thus operates upon the clavicle. 
The natural distance between the shoulders having been 
regained, pressure must be made upon the extremity of the 
reduced bone with the hand, until a suitable bandage can 
be applied. 

After-treatment. — The retentive means employed to 
maintain the reduction should accomplish two indications : 
viz., to prevent the shoulder from falling downwards, for- 
wards, and inwards, and to exert a certain degree of pres- 
sure upon the dislocated extremity of the clavicle. If the 
humeral end of the bone has 
been luxated, both of these 
indications will be fulfilled 
by the application of the 
figure 8 bandage of both 
shoulders, a pad being placed 
in the axilla of the affected 
side and a compress upon 
the end of the bone (fig. 81), 
while the forearm is sup- 
ported in a sling upon the 
front of the chest. If the 
accident has occurred to 
the sternal extremity of the 
clavicle, the same bandage 

should be employed, with the addition of a compress upon 
the injured articulation, to be retained in this situation by 
means of a few turns of a roller made to encircle obliquely 
the upper part of the chest, passing across the root of the 
neck of the injured side, over the sternal extremity of the 
clavicle, under the axilla of the sound side, and so around 
the back to the starting-point. 




CHAPTER II. 

DISLOCATIONS OF THE BONES OF THE UPPER 
EXTREMITY. 

SECTION I. 

DISLOCATIONS OF THE HUMERUS. 

The head of the humerus is liable to three principal va- 
rieties of displacement, viz., 1st, in the direction down- 
wards into the axilla ; 2d, forwards, under the pectoralis 
major muscle ; 3d, on the dorsum of the scapula. 

In all of these, the principle of reduction is the same, 
varying only in the line in which the reducing force is 
made to operate. There are, however, several methods 
by which the restoration may be accomplished. 

1. By the heel in the axilla. The patient should assume 
the recumbent position on a bed, or on the floor ; the sur- 
geon sits by his side, and places one heel in the axilla, in 
contact with the head of the humerus, thus fixing the body; 
the extending force is applied either to the arm above the 
elbow, or to the wrist. By the former plan, the surgeon 
flexes the patient's forearm so as to relax the biceps muscle, 
and secures a double roller-towel upon the arm above the 
elbow, by means of a wetted bandage; he then passes the 
towel over his own neck, and under the axilla of the side 
next the patient. (Fig. 82.) It may be objected to this 
method, that the triceps and biceps muscles may be stimu- 
lated to contraction by the pressure exercised upon them, 



DISLOCATIONS OF THE HUMERUS. 

Fig. 82. 



241 



V'U! 1 


'Jfe 


r«£ 


■miirr 


:\,a#.W*' 


:!!!!)« 










"'""IF— ■ 


■mill 




/Vfc, 



















and thus oppose the reduction. By the other mode, the 
surgeon grasps the patient's wrist either with the hand, or 
through the medium of a bandage, or of a double towel ar- 
ranged in the manner above described. The last method 
is probably the best, as it does not directly affect the mus- 
cles which pass from the scapula to the lower part of the 
humerus and the forearm. By employing the double towel, 
in either mode of operating, the surgeon may avail himself 
of the power of the muscles of the back, as well as of those 
of the arms. The extension should be made gradually and 
steadily in the direction assumed by the humerus, and the 
head of the bone may be acted upon by the heel of the sur- 
geon also, so as to be dislodged from its position in the axilla. 
2. By relaxing the supra-spinatus muscle and the deltoid, 
which, according to Sir A. Cooper (op. cit., pp. 321, 2), 
are the chief opponents of the reduction. The patient lies 
down, as in the first method ; the surgeon sits behind him, 
and extends the dislocated arm with one hand, while with 
the other he fixes the scapula. (Fig. 83.) If this simple 
manual force is not sufficient, the scapula may be secured 
by means of a double towel passed around it, crossing the 
axilla, and confined to the bedstead, or to the floor, on the 

21 



242 DISLOCATIONS OF THE HUMERUS. 

opposite side of the patient ; while pulleys are employed to 
make the necessary extension, as will be explained di- 
rectly ; or, again, extension may be effected by means of 
the double towel passed around the surgeon's back and 
shoulder, as already described. 

Fig. 83. 




3. By the pulleys. It is necessary, in the employment 
of the pulleys, to fix the scapula by some mechanical means. 
This maybe best accomplished by a broad piece of canvass, 
or leather, in which a hole is made large enough to admit 
the shoulder ; this band should pass in front of and behind 
the chest, and be secured to a hook in the wall, or the floor 
if the patient is in the recumbent position. The annexed 
drawings from Fergusson, illustrate the kind of pulleys 

Fig. 84. 




DISLOCATIONS OF THE HUMERUS. 



243 



which are used, and the ring to which one of their hooks is 
attached during the extension. (Fig. 84.) The other hook 
should be fastened to a towel, which has been secured upon 
the arm above the elbow, by means of a wetted roller. 
The cord of the pulleys should be drawn, by an assistant, 
slowly and steadily, and be relaxed as soon as the surgeon, 
who has his hands upon the head of the bone and the shoul- 
der, feels that the former has been drawn out from beneath 
the glenoid cavity. It may be of service sometimes, that 
the surgeon should place his knee beneath the humerus 
near to its head, in order to gain a fulcrum upon which, 
by depressing the elbow, the head of the bone may be ele- 
vated towards the glenoid cavity. (Fig. 85.) 

Fig. 85. 




The use of the pulleys is necessary in cases where, from 
long-standing dislocations, or from the great muscular 
powers of the individual, a very considerable, and a very 
steady and long-sustained force is required to reduce the 



244 DISLOCATIONS AT THE ELBOW- JOINT. 

head of the bone. In such instances, resort should be had 
to general depressing means, as bleeding, the administra- 
tion of nauseating doses of tartar emetic, &c. 

Any of the varieties of dislocation of the humerus may- 
be reduced by these means, but the direction in which the 
extending force should act, must be modified with each 
luxation. In the dislocation downwards, the arm should 
be drawn downwards and a little outwards from the side, 
to correspond with the direction of the axis of the humerus. 
In the luxation forwards, the arm points outwards and 
backwards, and the reducing force should operate in the 
same direction. When the head of the bone is thrown 
upon the dorsum of the scapula, the extension must be 
made forwards and outwards. 

After-treatment. — The forearm should be supported in 
a sling, in the semi-flexed position, on the chest, a pad should 
be secured in the axilla, and the arm bound, with a mode- 
rate degree of pressure, to the side. Local antiphlogistic 
applications, as lead-water, cold poultices, or leeches, may 
be made as required. The apparatus should be continued 
for ten days or two weeks. 

SECTION II. 

DISLOCATIONS AT THE ELBOW-JOINT. 

Of these there are six varieties : 1st, in which both bones 
are thrown backwards, the olecranon process projecting 
very much posteriorly ; 2d, in which both bones are drawn 
backwards and inwards ; 3d, when both are thrown back 
wards and outwards ; 4th, the ulna alone is forced back- 
wards, the orbicular ligament of the radius being ruptured, 
but this bone itself remaining on the anterior face of the 
external condyle ; 5th, the radius forced forwards into the 
depression above the external condyle, the ulna remaining 



DISLOCATIONS OF THE FOREARM. 245 

in situ ; 6th, the radius thrown backwards behind the ex- 
ternal condyle of the humerus. In all the varieties, the 
reduction is generally easily effected. In the first four 
species, the restoration may be accomplished by placing 
the knee at the bend of the elbow, and flexing the forearm 
upon it, the lower part of the upper arm and the forearm 
being grasped by the hands of the surgeon. The disloca- 
tions of the radius may be remedied by fixing the humerus 
and making extension from the hand, while the bone is 
thrown forwards ; if the luxation be backwards, the same 
extension and counter-extension should be made, while at 
the same time the forearm should be flexed, thus forcing 
the biceps to draw the radius to its proper place. 

Subsequent treatment. — The forearm should be placed 
in the semi-flexed position, and an angular splint should be 
bandaged upon the front of the whole limb, compresses 
being placed upon the head of the bones opposite the direc- 
tion of the luxation. This confinement must be maintained 
for two or three weeks, passive motion being carefully in- 
stituted after the first few days. 



SECTION III. 

DISLOCATIONS OF THE LOWER EXTREMITY OF THE FOREARM. 

These accidents are usually caused by falls upon the 
hand. Both the radius and ulna may be thrown either 
backwards or forwards upon the wrist, causing consider- 
able projection in these situations, or one of the bones only 
of the forearm may be separated from its connexions and 
displaced anteriorly, posteriorly, or laterally. The reduc- 
tion is easily accomplished by simply extending and coun- 
ter-extending from the hand and the forearm, and making 
moderate lateral pressure at the same time, if the displace- 
ment be at the side of the wrist. 

21* 



246 DISLOCATIONS OF THE HAND. 

Subsequent treatment. — Place a straight splint on the 
front, and another on the back of the forearm and hand, 
with compresses on the anterior and posterior surfaces of 
the wrist, and secure the whole by a roller. The forearm 
should be supported in a sling. 



SECTION IV. 
DISLOCATIONS OF THE BONES OF THE HAND. 

Instances have been met with, in which some one or 
more of the carpal bones have been thrown from their 
natural positions, so as to form projections upon the back 
of the hand, without a wound of the integuments. They 
may generally be replaced by pressure : the reduction 
should be maintained, by placing compresses upon the 
palmar and dorsal aspects of the wrist, and upon these 
straight splints, the whole to be enveloped in the folds of a 
roller. The hand should be supported in a sling. 

The same treatment, conjoined with some degree of ex- 
tension in the reduction, is applicable to dislocations of the 
metacarpal bones, should they occur without laceration of 
the integuments. 

Dislocations of the phalanges may ordinarily be re- 
duced without much difficulty, if the accident is attended 
to soon after its occurrence. Sometimes restoration may 
be accomplished by simply bending the displaced pha- 
lanx over the head of the bone from which it has been dis- 
located, as represented in the annexed drawing. (Fig. 86.) 
Frequently, however, considerable extension and counter- 
extension are requisite. To effect this, a piece of cord 
should be wound around the phalanx, the skin being pro- 
tected by a covering of wetted buckskin ; then, the hand 
being fixed, the surgeon should extend the finger, at first in 



DISLOCATIONS OF THE HAND. 
Fig. 86. 



247 




the axis of the bone, and gradually flex it towards the palm, 
in order to relax the flexor muscles, if the dislocation be 
posteriorly; or, if the phalanx has been thrown upon the 
palmar face of the other bone, it should be forced a little 
backwards, during the extension. (Fig. 87.) 

Fig. 87. 




The most convenient mode of securing the extending 
cord or tape, is by making 



what is termed the " clove- 
hitch," as shown in the ac- 
companying drawing, (fig. 
88,) from Fergusson. 

Dislocation of the pha- 
langes of the thumb is most 
difficult of reduction. The fol- 
lowing is the method recom- 
mended by Sir A. Cooper, 
p. 446 : " The extension is 
to be made by bending the 



Fig. 88. 




248 DISLOCATIONS OF THE HAND. 

thumb towards the palm of the hand, to relax the flexor 
muscles as much as possible, and the following is the mode 
of applying the extending force : The hand is to be first 
steeped in warm water for a considerable time, to relax 
the parts as much as possible ; then a piece of thin wetted 
leather is to be put around the phalanx, and as closely 
adapted to the thumb as possible : a piece of tape about 
two yards in length is next to be applied upon the surface 
of the leather, in the knot called the " clove-hitch," for this 
becomes tighter as the extension proceeds. An assistant 
places his middle and forefinger between the thumb and 
forefinger of the patient, and makes the counter-extension, 
whilst the surgeon, assisted by others, draws the phalanx 
from the metacarpal bone, directing it a little inward to- 
wards the palm of the hand." (Fig. 89.) 

Fig. 89. 




The quiescence of the joint after dislocation of the meta- 
carpal, or phalangial bones, is to be maintained by splints 
and compresses placed upon the dorsal and palmar aspects 
of the hand. 



CHAPTER III. 

DISLOCATIONS OF THE BONES OF THE LOWER 
EXTREMITY. 

SECTION I. 

DISLOCATIONS OF THE HIP- JOINT. 

Of these there are four chief varieties, named from the 
false position which the head of the os femoris assumes; 
they are as follows: — 1st, upwards, or on the dorsum ilii; 
2d, downwards, or into the foramen ovale ; 3d, backwards 
and upwards, or into the ischiatic notch ; 4th, forwards 
and upwards, or on the body of the pubis. 

These require, on the part of the surgeon, the employ- 
ment of a greater degree of force in reduction, than dislo- 
cations of any other bone, owing to the much greater power 
of the muscles concerned. In young children they may 
generally be restored by simple manual extension and 
counter-extension, as the luxations of the humerus ; but in 
adults, the pulleys should always be employed, and it is 
almost always advisable to have recourse also to depressing 
agencies, as bleeding to the amount of from twelve to 
twenty ounces, or the hot bath at 100°, or the administra- 
tion of tartar emetic in doses of half a grain every ten 
minutes until nausea is produced. (Sir A. Cooper.) 

As in other dislocations, the reducing forces should act 
gradually and steadily, and in the line of the axis of the 
dislocated bone, and during their operation, the patient's 
mind should be interested, if possible, in some subject 
other than his accident. 



250 DISLOCATIONS OF THE HIP-JOINT. 

The treatment of the individual dislocations is as 
follows : — 

1st. The dislocation upwards on the dorsum ilii. The 
patient is placed upon a table covered with a mattrass, or 
folded blankets. The pelvis is fixed by means of a sheet 
folded longitudinally, passed under the perineum and over 
the crista of the ilium, and secured to a staple so situated 
that the sheet may be in a line with the axis of the thigh. 
The extension is effected through the intervention of a 
w r etted roller secured upon the lower part of the thigh, and 
having buckled around it a leathern band with a short strap 
on each side terminating in a ring; the two rings are to 
be attached to the hook of the pulleys, and the latter 
secured to a staple in such a position that the extending 
and counter-extending forces may act parallelly to each 
other, from opposite points, and to the axis of the bone. 
Instead of the leathern band, a double towel may be con- 
fined to the thigh by the clove-hitch. The knee of the 
dislocated limb should be bent nearly at right angle and 
pointed across the thigh a little above the knee of the other 
leg. After the muscles have been fatigued by the con- 
tinued action of the pulleys, the surgeon should grasp the 
knee, and rotate the hip slightly and gently, or he may 
pass a towel around the upper part of the thigh, and raise 
thereby the head of the bone, when it will usually slip into 
the acetabulum, (fig. 90.) 

Fig. 90. . 



iow^ " li- -*n 



DISLOCATIONS OF THE HIP- JOINT. 



251 



The subsequent treatment consists in keeping the patient 
in bed for two weeks or more, his knees tied to each other 
by a strip of muslin, and a broad belt passed around his 
pelvis pressing upon the trochanters. 

2d. The dislocation downwards, or into the foramen 
ovale. To reduce this luxation, the following course should 
be pursued : The patient should be in the recumbent posi- 
tion, as in the first case ; a girth made of leather, or of a 
sheet, or towel, should be passed around the upper part 
of the thigh and attached to one of the hooks of the 
pulleys, the other being secured to a staple fixed in the 



Fig. 91. 



wall opposite the dis- 
located hip ; another 
girth should be made 
to encircle the pelvis, 
so as to steady the 
body, passing through 
the noose formed by 
the first girth, and 
attached to a staple 
placed opposite to the 
first, on the sound side 
of the patient. The 
cord of the pulleys 
should now be drawn 
until the head of the 
femur begins to leave 
its position in the 
foramen ovale, when 
the surgeon should 
pass his hand behind 
the ankle of the sound 
limb, and grasp the 
other ankle, which he 
draws steadily towards him ; the effect of this is, to throw 




252 



DISLOCATIONS OP THE HIP-JOINT. 



the head of the bone outwards, the limb being a lever with its 
fulcrum on the extending girth ; as soon as the head of the 
femur is sufficiently disengaged from its false position, the 
extending force should be suspended, when the limb will 
be restored, (fig. 91.) 

The after-treatment is as in the first case. 

3d. To reduce the dislocation backwards, or into the 
ischiatic notch : — Secure the extending and counter-extend- 
ing bands as in the first species of luxation ; then, the 
patient reposing upon his sound side, the knee of the dis- 
located limb should be pointed across the middle of the 
opposite thigh, and the extension practised until the mus- 
cles are enfeebled ; a round towel should now be passed 
under the upper part of the thigh, and over the shoulders 
of an assistant, who should be directed to press upon the 
pelvis with his hands, and at the same time to raise his 
shoulders : thus the head of the femur will be extricated 
from the ischiatic notch, and drawn downwards into the 
acetabulum. (Fig. 92.) 

Fig. 92. 




The subsequent treatment does not differ from that ad- 
vised for the other cases. 

4th. To restore the luxation forwards and upwards, or 
on the pubis : — The apparatus employed is the same as has 



DISLOCATIONS OF THE HIP- JOINT. 



253 



been already described, and its mode of application is as 
in the last-named variety of the accident. The patient 
should be placed upon his sound side, the knees widely 
separated from each other, and the extension made in a 
line behind the axis of the body. When the muscles have 
been sufficiently fatigued, a round towel should be passed 
under the upper part of the thigh, and around the shoul- 
ders of an assistant, who elevates the head of the femur 
by raising his shoulders, pressing at the same time upon 
the pelvis. (Fig. 93.) 

After-treatment. — The same as in the other varieties. 

Fig. 93. 




A very good and simple substitute for the pulleys has 
been recently recommended by Dr. Gilbert, Professor of 
Surgery in the Pennsylvania Medical College. Its mode 
of application is thus described in the American Journal 
of Medical Sciences, vol. ix., N. S. : — " Place the patient 
and adjust the extending and counter-extending bands as 
for the pulleys ; then procure an ordinary bed-cord, or a 
wash-line, tie the ends together, and again double it upon 
itself, pass it through the extending tapes or towel, doubling 
the whole once more, and fasten the distal end, consisting 
of four loops of rope, to a window-sill, door-sill, or staple, 
so that the cords are drawn moderately tight ; finally, pass 

22 



254 



DISLOCATIONS OF THE HIP- JOINT. 



a stick through the centre of the doubled rope, then by re- 
volving the stick as an axis, or double lever, the power is 
produced precisely as it should be in such cases, viz. : 
slowly, steadily, and continuously." (Fig. 94.) 

Fig. 94. 




Several instances of anomalous dislocations of the head 
of the femur are recorded by Cooper and others. (Sir A. 
Cooper, op. cit. pp. 83-97.) The means employed in the 
treatment of these are the same as in those varieties which 
have been already described. Proper reflection upon such 
cases will enable the surgeon to determine the probable 
position of the head of the bone, and the line in which the 
extension and counter-extension should be made, together 
with such other expedients as will assist in the dislodge- 
ment of the head of the bone from its unnatural position. 



DISLOCATIONS OF THE TIBIA AT THE KNEE. 255 

SECTION II. 

DISLOCATIONS OF THE PATELLA. 

The patella is liable to displacement in two directions, 
without rupture of its tendon or ligament, viz. : 

1st. Dislocation outwards, the bone resting upon the ex- 
ternal condyle of the os femoris, causing great projection 
at this point, and an inability to flex the knee. 

2d. Dislocation inwards, producing the same difficulty 
in bending the knee, with a marked prominence at the 
inner condyle of the femur. 

The restoration is generally easily accomplished, by re- 
laxing the extensor muscles of the leg: for this purpose the 
heel should be elevated upon the shoulder of an assistant, 
while the surgeon presses down the edge of the patella 
which is most removed from the centre of the knee-joint, 
thus tilting up the other edge of the bone, when the mus- 
cles, aided by a lateral pressure, will draw the patella to 
its place. 

The subsequent treatment consists in confining a straight 
splint to the posterior surface of the limb, and in making 
moderate pressure upon the knee by means of a roller, or 
a laced bandage ; local antiphlogistic applications are ge- 
nerally required, in addition. The patient should be con- 
fined to bed for about two weeks. 

SECTION III. 

DISLOCATIONS OF THE TIBIA AT THE KNEE. 

Of these there are four varieties, viz. : 

1st. Displacement forwards, — the tibia being thrown upon 



256 DISLOCATIONS OF THE HEAD OP THE FIBULA. 

the anterior part of the thigh, of which the condyles are 
depressed backwards, and somewhat to the side. (Cooper.) 

2d. Backwards, — the tibia drawn upwards behind the 
condyles of the femur, which project very much on the 
front of the leg. 

3d. Inwards, — the internal condyle of the thigh-bone 
resting upon the external semilunar cartilage. 

4th. Outwards, — the inner semilunar cartilage being in 
contact with the external condyle of the femur : the great 
lateral projection of the head of the tibia in these cases 
renders the diagnosis of the injury very easy. 

These dislocations are readily reduced by making ex- 
tension and counter-extension from the ankle and thigh, 
conjoined with moderate pressure upon the head of the 
tibia. After the restoration is accomplished, the limb 
should be secured to a straight splint, and such local anti- 
phlogistic means should be employed as the circumstances 
of each case may call for. The patient should be kept in 
bed for ten days or two weeks, or longer, if there be con- 
tinuance of pain or of inflammation. 

SECTION IV. 

DISLOCATIONS OF THE HEAD OF THE FIBULA. 

The head of the fibula is sometimes detached from its 
connexions with the tibia, and drawn backwards by the 
action of the biceps. It is easily restored to its place, by 
flexing the leg so as to relax this muscle, and pressing the 
bone forwards. 

In order to retain it * in situ,' the leg should be kept bent 
over a pillow, or an inclined plane, with a compress bound 
against the posterior part of the head of the bone by means 
of a roller- 



DISLOCATIONS OF THE ANKLE. 257 

SECTION V. 

DISLOCATIONS OF THE ANKLE. 

The astragalus may be separated from the bones of the 
leg in four directions, viz.: forwards, backwards, outwards, 
and inwards. The recognition of the accident is easy, and 
the reduction not difficult. The limb should be flexed so 
as to relax the powerful muscles on the back of the leg ; 
then, while extension and counter-extension are made from 
the foot and the lower part of the thigh, the surgeon should 
press firmly upon the dislocated bone, and thus force it to 
its place. 

After reduction, the leg and foot should be confined in 
carved splints, or splints made of binder's board soaked in 
hot water and moulded to the shape of the limb, with a 
foot-piece at right angles ; or a fracture-box will be found 
to answer equally well. This confinement to bed and in 
splints should continue for five or six weeks, and when the 
patient is first allowed to walk, the ankle should be care- 
fully supported by a roller bandage, or a firm laced gaiter. 
The time requisite to perfect the cure of these accidents is, 
according to Sir A. Cooper, ten or twelve weeks. 

If the fibula alone is separated from the tibia, simple 
lateral pressure will restore it to its place, after which a 
roller and compress should be employed for some weeks to 
retain the bones in apposition; rest is necessary as in the 
last-described injury. 

The remarks made on the treatment of dislocations of 
the bones of the hand and wrist are applicable to the same 
kinds of injury of the foot ; the treatment to be pursued in 
the reduction, and subsequently, is similar, excepting that 
a greater degree of force is required to reduce the luxation, 
and a longer confinement afterwards, when the foot is in- 
volved than when the hand is injured. 

22* 



CHAPTER IV. 

COMPOUND DISLOCATIONS. 

These accidents require the same sort of treatment as 
compound fractures. Much experience, and careful ex- 
amination of all the circumstances connected with each 
case are necessary, to enable the surgeon to determine 
when to attempt to save a limb so injured, and when to 
amputate. This volume does not pretend to lay down rules 
for such cases. The reader will do well to consult the 
works of the Coopers, Vidal (de Cassis), Boyer, Chelius, 
and others, with reference to this important subject. 

If an attempt to save the limb be decided on, the wound 
should be carefully cleansed, all foreign bodies, spicula, or 
small and detached fragments of bone, removed, hemor- 
rhage arrested, and the dislocated bone restored, if possible. 
Then the edges of the wound should be apposed to each 
other, and covered, as in the case of compound fractures 
of the patella, &c, with a piece of lint dipped in blood, or 
in some agglutinative fluid, and every effort should be made 
to convert the injury into a simple dislocation. The ten- 
dency to re-displacement should be overcome by placing 
the limb in such a position as shall relax the most powerful 
muscles connected with the dislocated bone, and by the 
application of a bandage to make moderate compression 
upon the seat of injury and on the implicated muscles. The 
disposition to inflammation, or this condition itself, should 
be combated by leeches, occasionally by general bleeding, 



APPARATUS FOR THE RELIEF OF ANCHYLOSIS. 



259 



by irrigation with cold water, by evaporating lotions, and 
by position. Warm applications should be avoided, so 
long as there is any prospect of closing the wound by di- 
rect union. Perfect rest should be maintained in bed, if 
one of the lower extremities be involved, and such splints 
and other retentive and supporting appliances should be 
employed as will most conduce to the objects in view. 



APPARATUS FOR THE RELIEF OF PARTIAL ANCHYLOSIS. 



Fig. 95. 



It not unfrequently happens after fractures involving a 
joint, dislocations, and other injuries or diseases, 4hat the 
motion of the joint is very much impaired, and the useful- 
ness of the whole limb much diminished. The difficulty 
may often be entirely relieved or lessened, by adapting to the 
limb some instru- 
ment, whereby con- 
stant and gradually 
increasing motion 
may be given to the 
joint for a length 
of time. The ac- 
companying draw- 
ing (fig. 95) exhi- 
bits an apparatus 
of this kind for the 
arm, which is re- 
commended by Professor Mutter, in his edition of Mr. 
Liston's " Lectures on the Operations of Surgery," &c, (p. 
433, Am. edit., 1846.) It consists of steel splints curved to 
the shape of the arm and forearm, and well padded, two 
for the upper arm and two for the forearm, for the anterior 
and posterior surfaces of the limb. The anterior splints 




260 APPARATUS FOR THE RELIEF OF ANCHYLOSIS. 

are connected by a steel or iron bar, which is firmly se- 
cured to them on each side, and jointed by a pivot at the 
centre, so as to move freely like a hinge. A " Stromeyer's 
screw" is fastened to the centre of the same splints in front, 
by moving which the apparatus may be made straight or 
angular, at pleasure. The splints are now applied to the 
limb, those for each division of the member being secured 
to each other by means of straps and buckles, and thus 
made to surround the arm above and below its bend, care 
being had that the joint of the side bars is opposite the 
centre of motion of the elbow. When the apparatus is 
thus properly applied, the screw should be turned until the 
patient *commences to experience slight uneasiness in the 
joint ; this process should be repeated daily, now extending 
and now flexing the limb, — avoiding the infliction of pain 
in the joint, — until an adequate degree of motion is restored: 
the action of the apparatus will be very much aided by 
frequently soaking the joint in warm water. 

When so elegant a splint as that employed by Dr. Mutter 
cannot be obtained, the same effect may be had by attach- 
ing the screw to simple splints of wood. The apparatus 
may be adapted to the knee as well as to the elbow, and 
with equally good results. 



PART V. 

ON SOME OF THE MINOR SURGICAL OPERATIONS. 

CHAPTER I. 

ON BLOODLETTING. 

Blood may be drawn from a vein or artery of some size, 
constituting what is termed " general bleeding," or from 
the smallest vessels which ramify beneath the surface, by 
means of cups and leeches, " local bleeding." The former 
method of abstracting blood is practised when the amount 
to be drawn is considerable, or when a general depressing 
effect upon the system is desirable ; the latter, when a par- 
ticular part only of the economy is affected, — the system 
generally being little, or not at all, involved. Sometimes, 
however, the indications for resorting to both operations 
exist in the same case and at the same time : under such 
circumstances, both general and local bloodletting should 
be practised, the former from a vein, usually, the latter 
from the vicinity of the suffering organ. 

In cities, these operations are generally performed by a 
class of persons who devote themselves to this duty as an 
occupation. In the country, the practitioner himself must 
attend to them. Every medical man, however, should be 
well acquainted with the methods of operating, and, whe- 
ther he live in the city, or in the country, should be skilled 
in the practice of general bleeding, at least, since he will 
be often compelled to resort to it. 



262 



ON THE OPERATIONS FOR GENERAL BLEEDING. 



SECTION I. 



ON THE OPERATIONS FOR GENERAL BLEEDING. 



These consist in the opening of a vein or an artery ; the 
former is much the most commonly practised, and should 
always be preferred, if a choice can be made. The inci- 
sion of a vein is termed phlebotomy ; that of an artery, 
arteriotomy. 

Phlebotomy. — 1. One of the veins at the bend of the arm 
is usually selected for bleeding, because these vessels are 
very superficial and convenient of access in this region, 
and are of sufficient size to allow the requisite amount of 
blood to escape freely and rapidly. The annexed draw- 
ings give a very good view of the veins of this region, as 



Fig. 96. 



Fig. 97. 





ON THE OPERATIONS FOR GENERAL BLEEDING. 263 

they are generally distributed, with their positions rela- 
tively to the artery and the superficial nerves (figs. 96 and 
97). In figure 96 are displayed: " 1, the radial vein ; 2, 
the cephalic vein ; 3, the anterior ulnar vein ; 4, the pos- 
terior ulnar vein ; 5, the trunk formed by their union ; 6, 
the basilic vein, piercing the deep fascia at 7 ; 8, the me- 
dian vein ; 9, a communicating branch between the deep 
veins of the forearm and the upper part of the median vein ; 
10, the median cephalic vein; 11, the median basilic; 12, 
a slight convexity of the deep fascia, formed by the bra- 
chial artery. This fascia is divided and turned aside in 
fig. 97, to show the brachial artery; 13, the process of 
fascia, derived from the tendon of the biceps muscle, and 
separating the median basilic vein from the brachial ar- 
tery; 14, the external cutaneous nerve, piercing the deep 
fascia and dividing into two branches which pass behind 
the median cephalic vein; 15, the internal cutaneous nerve, 
dividing into branches which pass in front of the median 
basilic vein; 16, the intercosto-humeral cutaneous nerve; 
17, the spiral cutaneous nerve, a branch of the musculo- 
spiral." Druitt, p. 494. 

The median cephalic and the median basilic veins are 
those in which the incision is generally practised in bleed- 
ing. The median basilic is the larger of the two, and 
would seem therefore to be the most proper for the opera- 
tion, and it is also more superficial than the other ; but the 
brachial artery is situated very near it, passing beneath it 
from the external side, and separated from it only by the 
thin aponeurosis from the tendon of the biceps muscle, so 
that an incision too deep would probably penetrate the ar- 
tery as well as the vein, as has not unfrequently happened ; 
moreover, this vein is crossed in front bv several filaments 
of the internal cutaneous nerve which, as they are invisible 
to the operator, are liable to be involved in his incision. 



264 ON THE OPERATIONS FOE GENERAL ELEEDING, 

Therefore it is safer to open the median cephalic rein, as 
this is remote from the artery : and as regards the liability 
of wounding one of the nervous filaments, the danger is 
rather less than in the other case, the external cutaneous 
nerve passing beneath it; the superior part of this vein, 
according to M. Lisfranc, is never crossed by nervous 
twigs. With regard to injury of the nerves in bleeding at 
the elbow, M. Velpeau says, that " all the veins at this part 
of the arm are surrounded by nervous filaments, and that 
with reference to this point, it would be ridiculous to open 
one in preference to any other." (Op. cit, p. 293.) Pro- 
bably the best rule is, to bleed from the median cephalic 
vein, provided it is sufficiently large to allow the blood to 
flow with freedom. If the median basilic be selected, 
the incision should be made, if possible, either above or 
below the point at which the vein crosses the artery, and 
not directly over the latter, the artery becoming more 
deeply situated as it leaves the vein. Sometimes the arte: 
runs parallel with this vein ; in such cases the forearm 
should be forced into a state of pronation, so that the ten- 
don of the biceps shall be made to intervene between the 
two. 

In all cases, the operator should carefully examine the 
part to see that there is no anomalous distribution of the 
arteries, and to guard against danger from this cause. 

It often occurs that in females and in children, the veins 
are scarcely, if at all, visible, the adipose tissue being so 
abundant Sometimes they may be made apparent, by al- 
lowing the ligature to compress the arm above the elbow 
for a considerable time, by plunging the forearm in warm 
water, by friction of the member, and by directing the pa- 
tient to call the muscles of the hand and forearm into ac- 
tion. Generally, however, if the veins cannot be seen, 
they may be felt beneath the surface, like round elastic 



ON THE OPERATIONS FOR GENERAL BLEEDING. 265 

cords, not pulsating as the artery, and losing their promi- 
nent corded form, and their elasticity, when the compres- 
sion is removed and the blood permitted to flow along its 
channels, regaining these characteristic marks when the 
pressure is resumed; the tendon of the biceps has been 
mistaken for a deep-seated vein, and has been cut in at- 
tempts to bleed; such an error ought never to occur, as 
apart from the criteria above mentioned for distinguishing 
a vein, the tendon may be easily recognised by flexing the 
forearm and marking the increased prominence which it 
thereby acquires. 

Before opening the vein, the surgeon should procure, and 
have arranged in some convenient position, a narrow strip 
of muslin, or linen, with which to arrest the circulation in 
the veins of the forearm ; a lancet ; a vessel to receive the 
blood as it flows from the incision ; a basin of water and a 
towel, to cleanse the surface after the operation ; a small 
compress of linen folded, to be placed over the wound, 
and a narrow bandage of muslin, or linen, to retain this in 
place; smelling-salts, or some other restorative, should also 
be at hand. 

The position of the patient during the operation is a 
matter of some consequence. If it is desirable to abstract 
a large quantity of blood, the recumbent posture should 
be assumed, as syncope occurs less speedily in this than in 
any other position ; when a rapidly prostrating, or relaxing, 
effect is required, as in cases of hernia or dislocation of the 
hip, the patient should stand up while the blood is flowing ; 
when an ordinary depletion only is indicated, and other 
circumstances permit of it, the sitting posture will be found 
the most convenient. The size of the opening, too, should 
be varied in different cases to meet particular views ; as 
for example, when a prompt effect is desired, the incision 
should be long, to allow the blood to escape in a full current ; 

23 



266 ON THE OPERATIONS FOR GENERAL BLEEDING. 

a small opening should be made when a gradual influence 
is intended to be produced. 

The choice of the arm on which to practise the operation 
may be left to the surgeon's discretion ; sometimes the 
veins are larger in one arm than in the other, and their 
relative position with regard to the artery may be more 
favourable in one than in the other. If there be no reason 
of this kind for selecting the right arm, it will be better to 
bleed from the left, since, if any accident should happen, 
the injury is more easily submitted to in the latter than in 
the former. 

Either the thumb-lancet, or the spring-lancet, may be 
used according to the habit, or the fancy, of the operator ; 
some prefer one, some the other, and occasionally a patient 
is met with who has strong objections against one or the 
other. There seems to be great diversity of opinion con- 
cerning the comparative safety of the two instruments. It 
is urged in favour of the use of the spring-lancet, that the 
operation is done more instantaneously with it than with 
the other, and with less pain ; and that it is less frequently 
attended with wound of the artery, in those cases in which 
the vein is entered at a point directly over this vessel; this 
last argument derives strong support from the statement 
of Dr. Reese, the American editor of Cooper's Surgical 
Dictionary, to the effect that aneurism of the brachial 
artery at the bend of the arm is much more commonly 
met with in the northern and eastern sections of this 
country, where the thumb-lancet is in general use, than in 
the southern and western and middle states, where the 
spring-lancet is employed very generally, and in many dis- 
tricts by very ignorant persons, as by the slaves on the 
southern plantations. The thumb-lancet is the most sur- 
gical instrument ; when of the proper shape and in per- 
fectly good order, as it always should be, the vein may be 



ON THE OPERATIONS FOR GENERAL BLEEDING. 267 

opened with sufficient quickness, and with no more pain 
than when the spring-lancet is employed ; the size of the 
incision can be more nicely graduated with the former than 
with the latter, and a deep-seated vein may be more cer- 
tainly reached with it : and as to the danger of penetrating 
the posterior wall of the vein and wounding the subjacent 
artery, if the thumb-lancet is used, the same amount of 
practice as is requisite to enable the operator to determine 
just how far from, or how near to, the skin it is necessary to 
hold the fleam of the spring-lancet,* in order that he may 
open the vein merely and not penetrate entirely through 
it, will render him capable of detecting, by the diminution 
in the resistance offered to the point of the thumb-lancet, 
the moment at which the cavity of the vessel has been 
entered by the instrument. It has occasionally happened 
in bleeding with the spring-lancet, that the fleam, or blade, 
of the instrument has been broken off, by the force of the 
spring, and has remained in the cavity of the vein, render- 
ing it necessary in some instances to slit open the vessel 
as far as the first valve, in order to remove the lancet. 
This accident is of rare occurrence, but the possibility of 
such an incident should be borne in mind. The spring- 
lancet will be found the most convenient instrument in 
bleeding children, in consequence of the struggles which 
they usually make, and which interfere very much with 
the performance of the operation when the thumb-lancet is 
used. 

The shape of the blade varies very much according to 
the fancy of the surgeon, or of his cutler ; we would re- 
commend one rather more oval-shaped at the point than 
that figured in drawing No. 98. The point and the edges 
of the instrument should be very sharp, and the blade as 
thin as is compatible with perfect strength and security. 



268 ON THE OPERATIONS FOR GENERAL BLEEDING. 

The lancet used for bleeding should never be employed for 
any other purpose, as cases have often occurred of inocu- 
lation of the wound with irritating or poisonous matters 
which have adhered to the blade. The instrument should 
be well cleansed and wiped dry after it has been in requi- 
sition, and kept in a suitable case. 

Operation. — The operation is commenced by encircling 
the arm, at a point an inch or two above the elbow, by a 
piece of ribbon, or a strip of muslin, an inch and a half 
wide and a yard and a half long. The arm should be 
bared nearly to the shoulder, care being had that the sleeve 
of the patient's dress exercises no constriction about the 
limb, impeding the flow of the blood through the artery ; 
then the surgeon, having carefully examined the bend of 
the arm, in order to ascertain the precise position of the 
brachial artery, and whether there be any anomalous dis- 
tribution of the vessels, places the centre of the compress- 
ing bandage upon the middle of the arm, at the point al- 
ready indicated, carrying the tails around on each side 
successively, and bringing them up over the anterior face 
of the arm, to tie them in a single bow-knot on its outer 
side, the extremities of the band hanging downwards. The 
bandage should be applied sufficiently tight to arrest the 
course of the blood in the superficial veins, but not to in- 
terfere with the circulation in the artery. If, as is some- 
times the case, the veins do not swell, the expedients before 
adverted to should be tried, and if these are ineffectual, the 
other arm should be taken, or a vein in some other part of 
the body may be opened, if it should be impossible to find 
a suitable vein in either arm. In such circumstances, M. 
Lisfranc advises that the cephalic vein should be exposed, 
where it occupies the interstice between the deltoid and 
pectoralis-major muscles, and an incision made in it. But 



ON THE OPERATIONS FOR GENERAL BLEEDING. 269 

there are few instances in which it is not possible to ab- 
stract the requisite amount of blood from one of the veins 
at the bend of the arm. The vein having been selected for 
the operation, and the exact situation of the artery with 
reference to it ascertained, the next step is, to make the 
incision. It is of great importance that the patient's arm 
shall be well secured, in order to avoid any accident which 
might ensue from a sudden movement of the limb, as the 
instrument pierces the tissues; this is of less moment when 
the spring-lancet is employed, than if the thumb-lancet is 
used. When the latter instrument is selected, the operator 
will find it of much advantage to be equally skilful with 
his right and left hands, as he can secure the patient's arm 
and perform the operation more satisfactorily. Thus, the 
arm should be thrown out from the body, and the surgeon 
should sit, or stand, between the limb and the side of the 
patient: if the right arm is to be operated upon, the elbow 
should be supported upon the outstretched fingers of the 
surgeon's left hand, his thumb pressing upon the vein, about 
an inch below the point of incision, in order to steady the 
vessel and to prevent a too great out-gush of blood from 
soiling the clothes, while the patient's forearm and hand 
are extended beneath the left forearm of the operator, and 
thus securelv held ; the lancet is of course entered with the 
right hand : if a vein of the left arm is to be opened, the 
surgeon modifies his position, so as to secure the arm with 
his own right hand and arm, and holds the instrument in 
his left hand. But if, as is the case with most persons, the 
operator cannot make the incision conveniently with his 
left hand, he must place himself on the outer side of the 
patient's left arm, securing the forearm with his own left, 
and open the vein with his right hand. 

The blade of the lancet should be exposed so as to form 

23* 



270 



ON THE OPERATIONS FOR GENERAL BLEEDING. 



Fig. 98. 




a slightly obtuse an- 
gle with the handles, 
and held as is repre- 
sented in the annex- 
ed drawing, (fig. 98,) 
being grasped near 
its head between the 
extremities of the 
surgeon's thumb and 
fore-finger, the handle resting against the latter. The ope- 
rator places his middle finger upon the patient's forearm, 
as in the figure, so as to support the hand : the point of the 
lancet is entered perpendicularly to the surface, if the vein 
is deep-seated, but at a more obtuse angle if the vessel is 
more superficial ; the mere straightening of the thumb and 
forefinger serves to force the point of the instrument 
through the integuments and the anterior wall of the vein, 
when, so soon as the escape of blood and the cessation of 
resistance to the entrance of the blade make the surgeon 
aware that the point is within the cavity of the vessel, he 
depresses the handle of the instrument, and at the same 
time pushes it a little forwards by his thumb and fore- 
finger, until the incision has been made sufficiently long, 
when the blade is withdrawn ; or it is perhaps safer to 
force the blade to cut its way out of the vein, so soon as 
the latter has been entered, by depressing the handle more 
and more, thus bringing the cutting edge in contact with 
the anterior wall of the vessel and with the integuments, 
successively : in this way there can be but little danger of 
penetrating the posterior coats of the vein with the point of 
the lancet. The incision should generally be somewhat 
oblique with regard to the axis of the vein, especially if 
the vessel be of small calibre, as otherwise the blood will 
escape more slowly. 



ON THE OPERATIONS FOR GENERAL BLEEDING. 271 

If the spring-lancet is used, it should be held more or 
less obliquely to the course of the vein, according as the 
vessel is of small or large calibre : when the vein to be 
opened is superficial, the point of the blade should be held 
a little above the skin, so that it shall simply enter the ves- 
sel, and not pierce entirely through it ; if, on the contrary, 
the vein is more deeply seated, the point of the fleam should 
rest upon the surface. In bleeding from a vein which is 
directly over the artery, the incision should be made upon 
the side of the vessel, instead of its anterior face, as being 
less liable to penetrate to the artery itself. 

If, after the incision has been made, the blood does not 
flow freely, the patient may be directed to grasp something 
in his hand, as a cane, closing and relaxing his fingers 
upon it alternately, thus compressing, by the contraction of 
the muscles, the deep veins, and forcing the blood into the 
more superficial channels ; the current through the vein is 
sometimes impeded by a constriction of the artery, arising 
from the too tight application of the bandage, which should 
of course be loosened : again, it may occasionally happen 
that a shred of adipose tissue may obtrude itself across 
the incision, and thus obstruct the escape of the blood ; the 
remedy for this difficulty will at once suggest itself to the 
operator. Syncope, accompanied by cessation of the flow, 
is at times produced by the dread of the operation which 
some persons experience, or by the sensation of the incision 
itself, or by the sight of the blood, in very sensitive pa- 
tients; in such instances, smelling-salts should be applied 
to the nostrils, cold water be dashed upon the face, and the 
ndividual be placed in the recumbent position, until the 
faintness shall have passed off, when the blood will flow 
again, generally. 

It is of little consequence what kind of vessel is employed 
to receive the blood as it escapes from the vein ; a common 



272 ON THE OPERATIONS FOR GENERAL BLEEDING. 

bowl answers the purpose as well as any other : however, 
if it be desirable to fix precisely the amount to be ab- 
stracted, the " bleeding-cup" proper should be used, — a 
vessel having lines upon its inner side graduated to show 
the number of fluid-ounces which it may contain: such 
bowls mav be had of most of the dru^cnsts. 

After the required amount of blood has been drawn, the 
bandage should be removed from the arm ; the edges of the 
incision approximated by the thumb and forefinger of the 
surgeon's left hand ; the surface cleansed ; the compress 
placed upon the wound, and retained in this position by 
the crossed bandage, as shown in figure 16. In applying 
the bandage, care should be had that it does not compress 
the arm above the opening in the vein more than below 
this point, otherwise the blood may again flow from the 
incision. After the lapse of twenty-four hours, during 
which time the patient should keep the elbow flexed, and 
avoid using the arm, — the bandage may be removed, as in 
most cases the orifice will have become sufficiently closed 
to prevent the escape of the blood. 

If it be probable that it will be expedient to repeat the 
bleeding in the course of twenty-four hours, the necessity 
of opening another vein may be avoided by anointing the 
compress with fresh lard, so that the orifice made in the 
vein will close less speedily than when a dry compress is 
applied. It is requisite merely to remove the bandage and 
encircle the arm, just above the elbow, with a band, as in 
the first bleeding : if the blood does not escape, on the vein 
becoming turgid, the hand should be passed upwards along 
the vessel, when the fluid will generally burst through the 
imperfectly closed incision ; if it do not, a fine probe may 
be used to re-open the wound. 

2. Bleeding from the hand. 

Operation. — Compress the forearm by a circular bandage 



ON THE OPERATIONS FOR GENERAL BLEEDING. 273 

applied just above the wrist, in order to render turgid the 
veins upon the back of the hand, and make an incision with 
a thumb-lancet into the largest of these vessels, in the same 
way as has been directed above with respect to the veins 
at the bend of the arm. The cephalic vein, formed by 
roots coming from about the thumb and forefinger, and the 
vena salvatella, from the other fingers, are the largest trunks. 
Care is necessary that the incision be not made so deep 
as to perforate the vein and wound the subjacent tendons. 

The wound, after the bleeding, should be covered as in 
the last- described operation. 

3. Bleeding from the ankle. 

Operation. — Plunge the foot in a basin of warm water, 
and allow it to remain until the veins running along the 
ankle shall have become swollen ; then remove the foot 
from the water, dry it, pass a circular bandage around the 
leg just above the malleoli, and open the internal saphena 
vein near the inner ankle, the vessel being fixed by the 
thumb of the left hand, placed just below the point of the 
intended incision. The opening should be oblique, and 
rather longer than is required for the veins of the forearm, 
so that the blood may have every facility for its free escape. 
After the incision, if the current do not flow readily, the 
foot should be again placed in the water, in which case 
the amount drawn must be judged of by the discoloration 
of the water, or by the effect produced upon the patient. 

The operator should be careful to regulate the force 
with which he makes the incision according to the volume 
of the vein ; otherwise, by penetrating too deeply, he incurs 
the liability of breaking the point of his lancet against the 
bone. The thumb-lancet should be used. The external 
saphena vein is sometimes opened at the outer ankle, but 
it is rarely so large as the other. The operation is per- 
formed as on the internal saphena. 



274 ON THE OPERATIONS FOR GENERAL ELEEDING. 

The requisite amount of blood having been removed 
from the vessel, a small compress should be placed upon 
the incision, the surface cleansed, and a figure g bandage 
applied to retain the compress, circling around the leg and 
the foot, above and below the ankles, leaving the heel ex- 
posed, and crossing upon the instep. 

4. Bleeding from the external jugular. 

This operation is rarely performed, partly in consequence 
of the more or less danger attending it, but chiefly because the 
required amount of blood can generally be taken from a vein 
at the elbow. It is sometimes advisable, however, to prac- 
tise this operation; as, for instance, in convulsions occurring 
in young children, in whom there is frequently much diffi- 
culty in bleeding from the arm ; also in apoplectic seizures. 

When it is determined to open the external jugular, the 
incision is usually made between the lower third of the 
vein and a point two inches above the clavicle. Below 
this point, there may be danger that the air will enter 
through the orifice to the heart, thus causing almost instant 
death. Above its lower third, the vein is so surrounded by 
nervous filaments that the incision of the former would, 
very probably, implicate the latter. 

Operation. — The patient is placed in a sitting, or in the 
recumbent, posture ; a thick compress should be laid upon 
the vein in the supra-clavicular fossa, and retained in this 
position by a strip of muslin, or a cravat, which crosses 
the chest obliquely from this point to the axilla of the op- 
posite side, where its tails are united, as in the accompany- 
ing drawing (fig. 99). In opening the vein, the surgeon 
places the thumb of his left hand upon the compress, and 
his forefinger upon the swollen vein, just above the point 
selected for the incision, and opens the vessel pretty freely 
in a line obliquely upwards and outwards, crossing the 
fibres of the platysma-myoid, so that the lips of the 



ON THE OPERATIONS FOR GENERAL BLEEDING. 



275 



Fig. 99. 




wound may be well separated. A tea-cup, or a small 
bleeding-bowl, should be held against the skin at the lower 
edge of the opening in the vein, to receive the blood as it 
escapes : or if the current do not jet from the orifice, a card 
should be bent to the form of a gutter, or trough, to convey 
the fluid into the cup. The compression should not be 
intermitted until the operation is completed, and the open- 
ing in the vein closed by another compress placed upon 
the wound: this precaution is intended to prevent the ingress 
of air. The compress may be retained in place by short 
strips of adhesive plaster laid across it, or by the circular 



276 ON THE OPERATIONS FOR GENERAL BLEEDING. 

bandage of the neck, described under the head of regional 
bandages. 

The escape of the blood may be facilitated, if it do not 
flow readily, by directing the patient to move the lower 
jaw, as in masticating. After the operation, difficulty is 
occasionally experienced in arresting the flow ; under such 
circumstances the recumbent posture should be maintained, 
all compression from clothes carefully removed, and the 
patient be directed to breathe freely and fully. M. Magistel 
closes the wound, in such cases, with a fine suture. 



ACCIDENTS ATTENDING PHLEBOTOMY. 

Fortunately these are rare, when the frequency of the 
operation is considered, and those which occur most fre- 
quently are so slight in themselves and in their conse- 
quences, as hardly to merit the appellation of accidents ; 
such are the formation of what is termed a thrombus, and 
syncope partial, or complete. The proper remedies for the 
latter have been mentioned, in treating of bleeding from the 
arm. A thrombus is a tumour, or swelling, generally of 
small size, produced by the infiltration of blood into the 
cellular tissue surrounding the vein. It is owing, in most 
cases, to the external incision not corresponding exactly in 
situation with the opening in the vein, the correspondence 
having become destroyed by some movement of the arm, 
or by a want of attention on the part of the operator, 
while making the incision, to have the skin tense and 
smooth ; any cause which will obstruct the ready escape 
of the blood from the vein to the external surface may de- 
velope a thrombus. Generally it is a matter of little con- 
sequence, giving rise only to some swelling, discoloration, 
and stiffness at the elbow, which inconveniences will dis- 



ON THE OPERATIONS FOR GENERAL BLEEDING. 277 

appear in a few days. Sometimes, however, if the effusion 9 
is large, the fluid is removed by suppuration instead of by 
absorption, and there is danger that the vein will become 
involved in the inflammation. 

The simpler cases of this incident to bleeding require 
very slight treatment ; the removal of the effusion will be 
hastened by keeping the arm at rest and covering the 
affected part with soap-plaster, or a wash of diluted spirits 
of camphor, or of some similar resolvent If inflammation 
and suppuration occur in the tumour, a splint should be 
confined upon the back of the arm and forearm, to main- 
tain perfect repose of the tissues about the elbow, and 
leeches, cold lotions, irrigation, or poultices, should be made 
use of, according to the condition of the tumour. 

By carefully watching the escape of the blood during 
the operation, the surgeon may often guard against, or 
arrest, the formation of a thrombus, by maintaining the 
parallelism between the wound in the integuments and that 
in the vein, or by restoring this condition if it has been de- 
ranged. If this correspondence cannot be regained, and 
the tumour increases in size, the^external incision should be 
enlarged sufficiently to permit of the blood reaching it, or 
another vein should be opened. 

Wound of a Nerve. — This accident may happen, and it 
has occurred to the most skilful operators in bleeding, and 
it cannot be considered as a subject of reproach. It will 
be recognised by some disturbance in the functions of the 
part to which the nerve is distributed. If the wounded 
nerve be a nerve of sensation, pain will be experienced at 
the seat of the incision, or at the terminal ramifications of 
the nerve, a sensation of numbness or of tingling, or the 
skin will be deprived of sensibility. If it be a motor nerve 
which has been implicated in the incision, the muscle, or 
muscles, to which it gives power will be more or less 

24 



278 ON THE OPERATIONS FOR. GENERAL BLEEDING. 

9 paralysed, or be the seat of irregular motor action, spas- 
modic twitches, tetanic rigidity, and the like. 

This accident is a much more serious one than those 
already considered, and should be so regarded. The treat- 
ment consists in the application of antiphlogistic, or anodyne 
remedies to the surface, according to the symptoms; in 
securing the limb to a splint in a semiflexed position, and 
in the administration of opiates internally. The limb 
should be kept in a state of perfect rest on a splint, for two 
or three weeks, or so long as there is any probability of the 
reunion of the cut extremities of the nerve, experiments 
and observations having shown that restoration of the 
functions of nerves simply divided does take place. (Car- 
penter's Human Physiol, p. 232 ; Miiller's Physiol, vol. i. 
p. 457, &c.) 

- Wound of an Artery. — The brachial arterv is the one 
most liable to be wounded in phlebotomy, and its acci- 
dental puncture may be taken as a type of similar injuries 
of other arteries. The signs usually mentioned as indicative 
of this accident are, the flowing of the blood in jets from 
the external opening, and the bright-red hue of the fluid. 
These appearances, however, are fallacious, for venous 
blood is not always of a dark blue colour ; in fact, in many 
persons and in some diseases, its colour approaches very 
nearly to the hue of arterial blood ; and if the vein which 
has been opened is seated immediately upon the brachial 
artery, the pulsations of this vessel will often agitate the 
vein, and communicate a jetting motion to the current as 
it escapes from the latter. The occurrence of the accident 
may be recognised pretty surely, by observing whether the 
blood continues to flow from the external wound, when the 
vein is compressed at the lower edge of the incision ; if 
such is the case, the artery has probably been opened, the 
only circumstance likely to mislead the observer arising 



ON THE OPERATIONS FOR GENERAL BLEEDING. 279 

from the communication of another vein with the one in 
which the aperture has been made, opposite the orifice; 
this must be a very unusual incident. Additional know- 
ledge may be acquired as to the non-existence of injury to 
the artery, by compressing this vessel at some point above 
the wound, when, if the colour of the blood remain as before, 
the inference from this fact, conjoined with the cessation of 
the flow when the vein is compressed below the orifice, while 
the artery still pulsates at the wrist, is, that only the vein 
has been opened. Again, if the external wound be closed 
with sufficient force to compress the vein merely without 
obliterating the artery, a gradually increasing tumour will 
be developed in the tissues, if the artery has been punctured. 
The existence of the injury having been ascertained, there 
can still be no impropriety in permitting the blood to es- 
cape until the amount originally intended to be drawn has 
been removed. Then the surgeon must determine, whether 
it is better, in the particular instance, to endeavour to 
remedy the accident by the long-continued employment of 
a compress and bandage, or to obliterate the artery at once 
by the application of a ligature, or ligatures. M. Velpeau 
recommends that the first method be tried for a week or 
two, unless some serious appearance present itself. (Vel- 
peau, op. cit. p. 312.) This course having been determined 
upon, a graduated compress should be formed, of a pyra- 
midal shape, and applied with its apex upon the wound, a 
figure-8 bandage being made to retain it in place with a 
degree of compressive force considerably greater than 
would be sufficient to obliterate the vein merely, so that 
the pulsation at the wrist shall be arrested ; the limb, from 
the fingers to the axilla, should be enveloped carefully in a 
roller-bandage, and maintained in a state of perfect rest 
upon a splint, in the straight position ; the patient should 
remain in bed, or his arm should be supported in a sling. 



280 ON THE OPERATIONS FOR GENERAL BLEEDING. 

If, after compression has been employed, the formation of 
an aneurism be detected, the treatment necessary for this 
affection must be adopted ; for this, and for the best method 
of obliterating the artery by ligature, if the treatment by 
compression be rejected at first, the reader is referred to 
treatises on practical surgery. 

Wounding of the Tendon of the Biceps, or of other 
Muscles. — It happens occasionally that one of the tendons 
is pricked by the point of the lancet, when it is seated be- 
neath the vein which has been opened ; or the operator 
may have mistaken the tendon for the vein, and plunged 
his lancet therein. Some degree of pain and difficulty in 
using the muscle are generally experienced, after such an 
accident, but the symptoms are rarely of a violent charac- 
ter. The treatment consists in keeping the limb at rest 
upon a splint, the muscle being relaxed, and in the applica- 
tion of anodyne and emollient remedies. In irritable 
patients, it may be advisable to abstract blood from the 
part, by leeches, and to administer opiates. 

ARTERIOTOMY. 

The temporal artery is the only one upon which this 
operation is now practised, and very rarely is it considered 
advisable, even on this vessel. The artery is superficial, 
is favourably situated for compression after the operation, 
and is generally large enough to allow of the abstraction 
of a sufficient amount of blood. Although the incision of 
the vessel is one of the simplest of operations, it is some- 
times followed by the development of an aneurism. 

A strong lancet, or a bistoury, — a graduated compress, — 
a narrow roller, two or three yards long, — warm water 
and a towel, are all that are usually needed for the ope- 
ration. 



ON THE OPERATIONS FOR GENERAL BLEEDING. 281 

The trunk of the temporal artery itself, or its anterior 
branch, may be opened ; if the former, the mode recom- 
mended by M. Magistel may be resorted to, as follows : — 
The position of the trunk is ascertained at the point where 
it is most superficial, and where its pulsation is most 
forcible, and there marked with ink in the direction of the 
intended incision : this point will be found a little in advance 
of the ear, and above the zygomatic arch. The patient 
may sit up, or assume the recumbent position, his head 
resting upon a pillow on the opposite temple ; the surgeon 
steadies the artery by one finger placed upon the surface, 
on the outside of the vessel, and about a quarter of an inch 
above the site of the intended incision ; the bistourv is held 
as the lancet in phlebotomy, and entered through the in- 
teguments on the inner side of the artery, cutting its way 
obliquely through the vessel and the integuments of the 
opposite side. The blood is received directly in a cup, or 
it is guided to the latter through a little gutter of paper, 
placed against the surface beneath the opening: a plug of 
cotton should be inserted into the chamber of the external 
ear, to prevent the blood from entering it. When the 
proper amount has been drawn, the flow is generally easily 
arrested by placing a small compress of folded linen upon 
the orifice, (its lips having been placed in apposition,) and 
securing it thus by a few circular turns of a roller. If this 
be insufficient to stop the bleeding, a fine suture may be 
passed through the edges of the wound. (Malgaigne, Med. 
Operat.) 

If the blood do not flow freely, the patient, if he be con- 
scious, should be requested to move his jaw, as in mastica- 
tion, or a sponge filled with warm water may be laid upon 
the vessel. 

M. Velpeau advises that one of the branches of the 
artery be selected for the operation, particularly the an- 

24* 



282 ON TOPICAL BLEEDING. 

terior branch in its course towards the forehead, as it is 
very superficial and reposes so nearly upon the bone that 
a firm compression may be made upon it. The mode of 
performing the operation is the same as for the trunk itself: 
the lancet may be used as in opening a vein, or a bistoury 
may be employed, and the integuments and vessel divided, 
from the former towards the latter, and from the outer side 
of the artery towards the operator. See fig. 99. 



SECTION II. 

ON TOPICAL BLEEDING. 

1. On the application of the cupping apparatus. 

In professional language, "<z cup" is a small, bell-shaped 
vessel, made of glass, or thin metal, intended for applica- 
tion to the surface of the body, with the view either of 
removing a certain amount of blood from the minute veins 
and arteries which have been previously incised, or of 
merely producing a congestion of the surface, or a certain 
degree of ecchymosis. The first is termed " wet-cupping," 
or simply " cupping," the latter " dry-cupping." 

Dry cupping is effected by merely acting upon the air 
within the cup, so that the integuments, on the surface of 
which it is placed, shall be forced, by the pressure of the 
atmosphere without, into the partial vacuum formed within 
the vessel. This vacuum may be produced in several dif- 
ferent ways, either by means of heat so applied as to rarefy 
the air within the enclosure, or by the direct abstraction of 
a certain portion of it through the aid of a pump. The 
latter is the most convenient and the most eligible mode. 
The pump is made to fit upon the summit of the cup, which 
is perforated with a small hole covered with a thin valve 



ON TOPICAL BLEEDING. 283 

of oil-silk, or of gum-elastic, to exclude the entrance of air 
from without ; while, by the action of the pump, a very 
considerable exhaustion can be effected within the cup. 
The cup is best made of glass, so that the degree of 
turgescence of the integuments can be seen ; when this 
is deemed sufficient, the glass is easily detached from the 
surface by slightly raising the valve by means of a pin 
inserted beneath it, when the pressure of the atmosphere 
within and without the cup will become equalized. 

If this complete cupping apparatus be not at command, 
the operation may be sufficiently well performed by using 
a common wine-glass, or tumbler. The vessel may be im- 
mersed in hot water, in order to heat its surface, and then, 
before it becomes cooled, applied upon the skin ; thus the 
air which it contains becomes rarefied by the heat of the 
material of which the cupping vessel is composed, and 
retreats before the ascent of the integuments, which are 
pressed upwards by the weight of the air surrounding the 
cup ; or the inner surface of the cup may be moistened 
with spirits of wine, which should then be inflamed, and 
while the vessel is yet warm, it should be placed upon the 
skin ; or, finally, small pellets of cotton, or strips of paper, 
may be moistened with the same fluid, then lighted and 
introduced into the cup, which is used as above. The 
vessel may be loosened from the surface after a proper 
time, by pressing upon the integuments at its edge, so that 
the air may rush into the cavity. 

Dry cupping will be found of great benefit in the relief 
of internal congestions, when it is not expedient to abstract 
blood. It seems not to produce its good effect by revulsion 
merely, or by the external irritation which it causes, but 
also by rendering the vessels on the surface turgid, pro- 
ducing a true ecchymosis, and thereby diminishing tempo- 
rarily the amount of fluid in circulation through the vessels. 



2S4 ON TOPICAL BLEEDING. 

Wet cupping requires that, in addition to the local tur- 
gescence which the dry cupping occasions, the surface 
thus engorged shall be incised, its small vessels opened, 
and blood be abstracted therefrom. To accomplish this 
object, the cupping apparatus must be used as above de- 
scribed, and after the integuments have become sufficiently 
full of blood, the cup should be removed and a number of 
incisions made on the surface, deep enough to open the 
subcutaneous vessels : then the cup is to be re-applied, and 
the air again exhausted from it; thus the blood will flow- 
readily from the openings made. After a sufficient amount 
has been obtained, the cup is removed and the surface 
cleansed ; generally, no dressing is called for, but if there 
be much smarting, cold or warm water or a piece of linen 
spread with simple cerate, may be applied, as may be most 
agreeable to the patient. In directing the use of cups, it is 
generally considered that each one will draw one ounce of 
blood ; this is not strictly correct, as the amount will van- 
very much, according to the vascularity of the part to 
which the application is made; sometimes a single cup will 
abstract several ounces if re-applied to the same spot, and 
again but a very small proportion of this amount can be 
taken. The flow of blood may be encouraged by immers- 
ing the cup, before it is placed upon the skin, in warm wa- 
ter, and by laying a sponge or towels dipped in warm 
water upon the surface, while the cup is acting. The depth 
of the incision must be regulated to suit the character of the 
surface : w^here the integuments are thick, containing- much 
adipose tissue, the incisions must be deeper than under op- 
posite circumstances. The proper instrument for making 
the incisions in cupping is the u scarificator," — a metallic 
bos of about the same size as the cup, having its inferior 
surface pierced with a number of slits, through each of 
which a lancet-blade is made to protrude by means of a 



ON TOPICAL BLEEDING. 285 

spring, the frame upon which the blades are secured being 
elevated or depressed, so as to regulate the depth of the 
incisions, by the turning of a screw arranged for the pur- 
pose. In the absence of this scarificator, the necessary in- 
cisions may be made by a scalpel, or a thumb-lancet ; they 
may be parallel to each other, or crossed, or have an ob- 
lique direction. 

The operation of cupping is sometimes a painful one, 
particularly upon surfaces not very well cushioned by in- 
tegument, as on the chest of thin persons, and also when 
performed over inflamed cavities, as upon the abdomen in 
gastritis, enteritis, or peritonitis ; but even in these latter 
cases, the operation may be effected with comparatively 
little pain, by first applying a poultice, or a fomentation, 
upon the surface ; thus the sensibility of the part becomes 
lessened. This is a matter of considerable consequence, 
as leeches cannot always be obtained in all situations; and 
by the simple precaution just stated, cups may be very 
well used instead, in numerous instances in which, other- 
wise, the advantages of local depletion must be foregone. 

It is of importance to bear in mind that the benefit of 
cupping does not consist in the local abstraction of blood 
merely, but also in the stimulation which it effects upon the 
surface to which the cups are applied, and in the revulsive 
action which is thereby occasioned. 

2. On the employment of leeches. 

There are many cases demanding local depletion, in 
which, from peculiarity of situation, or excessive sensitive- 
ness of the surface, cups cannot be employed ; in such in- 
stances, leeches may be used, as also in all other condi- 
tions requiring the topical abstraction of blood. 

Previous to the application of the leech, the surface on 
which it is to be placed should be cleansed with warm 
water, so as to remove, as far as possible, any matter which 



2SG 



ON TOPICAL BLEEDING. 



may adhere to the skin, either as the result of medicinal 
applications, or as incident to the natural or diseased pro- 
cesses going on in the part : if this precaution be not taken, 
much difficulty and delay will be experienced in inducing 
the leech to fasten upon the surface, and the animal itself 
may be injured or killed, by the introduction into his sys- 
tem of such noxious matter. If the surface to be leeched 
be covered at all thickly with hair, as the pubis, the scalp, 
&c, it should be shaved before the leech is applied to it. 
When a number of leeches are to be applied to a circum- 
scribed part, it is often found difficult to confine them 
within a sufficiently restricted range, if they are simply 
placed on the surface; this may be overcome by moisten- 
ing the skin, at different points, with blood drawn from the 
tip of the finger, or with sugar and water ; or the leeches, 
as many as are intended to be employed, may be put into 
a tumbler, or wineglass, which should then be inverted upon 
the skin : or, finally, the palm of the hand may be covered 
with a napkin, and the leeches placed upon the latter, and 
thus held against the surface until thev shall have attached 
themselves. When blood is to be taken from the mucous 
membrane lining a canal, it is necessary to place the leech 
in a tube which is then to be introduced into the canal, its 
open extremity applied to the membrane at the proper 
point, and there retained until the leech has fastened itself 
upon the surface. Thus if the depletion is to be effected 
from the neck of the uterus, the neck of the bladder, or 
from any part of the vagina, in the female, — a speculum 
of polished metal, made of a single piece, and having the 
upper end cut obliquely, should be introduced into this pas- 
sage to the proper distance, the polished internal face of 
the speculum enabling the operator to see each point of the 
vagina; the leeches are now to be placed in the speculum, 
and thrust up to the affected spot by means of a quill, or a 



ON TOPICAL BLEEDING. 287 

stick. For the rectum, a smaller speculum is required. 
For the nostrils, a tube of glass slightly curved at its upper 
extremity, and about a quarter of an inch in diameter, 
gradually tapering towards the curve, may be used ; this 
should be introduced, and the point of the curvature car- 
ried opposite the spot upon which the leech is to be at- 
tached ; the animal is then to be placed in the cavity, and 
pushed upwards by means of a quill, or a pencil ; as soon 
as it has fastened upon the membrane, the tube may be 
withdrawn, and, if necessary, another leech introduced in 
the same way. A similar plan should be adopted in the 
application of leeches to the gums, or to the lining mem- 
brane of the mouth at other points. 

If, accidentally, one or more of these animals should 
escape beyond the reach of the operator, as into the sto- 
mach or rectum, it may be destroyed by injecting a solu- 
tion of salt into the cavity ; afterwards the leech will be 
discharged dead. 

Repletion causes the leech to fall from the surface upon 
which it had fastened ; but if it be expedient to detach it 
before it has become filled, fine salt should be placed upon 
it ; it should not be violently pulled from its hold upon the 
skin, lest a portion of its mouth remain in the little wound 
which it has made, causing more or less irritation and 
destroying the animal. 

The quantity of blood which a leech will draw varies 
very much with the kind of leech used, and the degree of 
vascularity of the surface. Six of the ordinary American 
leeches are allowed for each ounce of blood required ; these 
answer very well for application to the external surface, in 
situations possessing an average condition of the circula- 
tion, and offering space sufficient to allow of the applica- 
tion of the requisite number ; their bite is less irritating and 
less deep than that of the European leech, and hence they 



2S3 



ON TOPICAL BLEEDING. 



should always be employed upon children, and upon others 
whose skin is prone to a morbid degree of inflammation or 
soreness, from slight causes. An ounce of blood is gene- 
rally allotted, as the capacity of two or three Swedish, or 
Spanish, leeches. These are used when the part to be de- 
pleted is endowed with little vascularity, and upon internal 
surfaces of which the secretions are naturally, or from dis- 
ease, more or less acrid or offensive to the animal, as the 
mucous membrane of the vagina, that covering the neck 
of the uterus, the rectum, the gums; and it is advisable 
always, before applying the leech to such parts, to wash 
them with warm water. 

After the animal has fallen off, the blood continues to 
flow from the wound, but this ceases in the course of a few 
minutes, if the bite be left exposed to the air, unless a small 
arterial branch of notable size has been opened. If a suf- 
ficient depletion has been had, and the bleeding does not 
cease of itself, cold water should be laid upon the surface, 
or dry lint ; and if anything more effectual is necessary, 
pressure with the finger, a little fine lint intervening be- 
tween its point and the leech-bite, may be made upon the 
latter for a few minutes, and then the finger gently with- 
drawn, leaving the lint behind ; this will generally be suffi- 
cient to arrest the bleeding ; but if this fail, a fine point of 
lunar-caustic should be thrust into each bleeding wound, 
and quickly removed; finally, it is recommended, in obsti- 
nate cases of such hemorrhage, to pass a fine needle trans- 
versely through the lips of the wound, and to lay upon 
it a twisted suture; this, however, must be very seldom 
required. 

If it be deemed expedient to encourage the flowing of 
the blood, warm water should be laid upon the part, or a 
warm poultice. 

The preservation of the leech is a matter of great im- 



ON TOPICAL BLEEDING. 289 

portance. To insure this object, the habits of the animal 
should be ascertained, in order that it may be placed in 
circumstances in which these habits and instincts may still 
be indulged. It should be kept in some suitable vessel, — 
an ordinary tub will answer, — containing water, and pieces 
of turf, or, which is still better, of peat, into which the ani- 
mal may insinuate itself, and, by the friction of its surface 
against the interlaced roots of which the peat is composed, 
cleanse itself of the slimy secretion which covers it, and 
which, if permitted to remain long upon the exterior, pre- 
vents the proper performance of certain functions on which 
the health of the leech depends. The water should be 
changed as often as once every week, and the leeches 
should be washed, unless they have the means, as above 
described, of performing this office for themselves. The 
animal obtains its supply of oxygen from the air entangled 
in the water, and not by rising to the surface to breathe. 

In this way leeches may be preserved for an indefinite 
length of time, until needed for application ; but after they 
have been once employed in drawing blood, they never are 
so efficacious again. If they have been applied to abstract 
blood from persons suffering from some malignant or con- 
tagious disease, they should not be used subsequently. 

The natural food of the leech consists of smaller aquatic 
animals w T hich it meets with in its native haunts ; and the 
admirable apparatus with which it is provided, and which 
adapts it so perfectly to the purpose to which it is made 
subservient in the treatment of disease, would seem to be 
contrived for the especial benefit of man, — to be, in a mea- 
sure, an appendix to the animal, and not called for in the 
operations of its own economy. Hence, although the blood 
with which it fills itself to distension, in the gratification of 
its voracious thirst, does not putrefy in the animal's sto- 
mach, notwithstanding the length of time during which it 

25 



290 ON TOPICAL BLEEDING. 

will be retained in this cavity, unless it be evacuated arti- 
ficially, — in most cases, the animal will die unless the blood 
be removed from it. (T. Rymer Jones' Comparative Ana- 
tomy.) To accomplish this, it is requisite merely to place 
some fine salt, or salt w r ater, upon the leech, which will 
cause the animal to eject the contents of its stomach by the 
mouth. The author is informed by Mr. Moore, who is one 
of the best leechers in this city, that he effects the removal 
of the blood by making one or two small punctures on the 
back of the leech, on each side of the middle line ; the 
contents of the stomach and of the numerous sacciform 
appendages to this central cavity are evacuated through 
these punctures, which soon close again without hav- 
ing injured the animal at all. Mr. Moore prefers this 
method to the use of salt, which he thinks is in some mea- 
sure hurtful to the leech. Leeches which have thus been 
emptied of the blood that they have drawn, should be 
placed in a vessel containing water and turf, as above 
mentioned, and kept distinct from others for two or three 
weeks, after which they may again be employed. 

Simple scarification of the surface w r ith a lancet or scal- 
pel, is sometimes resorted to as a means of local depletion. 
It can only be employed on very vascular parts, as on the 
tongue, the mucous membrane lining the interior of the 
mouth, and that covering the fauces and the eyelids. 



CHAPTER II. 

ON THE DIFFERENT MODES OF EFFECTING 
CUTANEOUS IRRITATION. 

It has long been an established principle in medicine, 
that when a point of irritation exists in any part of the 
body, there will be a corresponding accumulation at that 
point of organic energy and of circulating blood ; and the 
physical and chemical changes which accompany every 
manifestation of organic action will be proportionately 
more rapid and complete. To admit of this concentration 
of vitality upon a particular part of the body, the system 
elsewhere seems to suffer, as it were, a transfer of some 
portion of the vital energy allotted to it. Hence the resort 
to counter- irritation, or revulsion, in the treatment of dis- 
ease: an exaltation of life is artificially occasioned in a 
particular part of the surface, with the view of diminish- 
ing or annulling the same condition, as the result of dis- 
ease, in another and generally neighbouring organ. By 
properly varying the means resorted to, the kind and de- 
gree of action thus established may be suited to the differ- 
ent states which it is the object of the surgeon to counter- 
act. These means are chiefly rubefacients, vesicatories and 
such as produce suppuration. 



292 



OF RUBEFACIENTS." 



SECTION I. 

OF RUBEFACIENTS. 



These are applications which excite an erythematous 
inflammation of the skin, terminating in complete resolu- 
tion, and followed frequently by desquamation of the cuticle 
upon which they were placed. Their local action is strictly 
counter-irritant, not combined with any depletory influ- 
ence ; but, in addition to this, they produce a considerable 
degree of general excitement. 

There are many applications which produce this effect: 
water, sand contained in a suitable vessel, and heated to a 
temperature somewhat above that of the surface of the 
body, (from 100° to 150°,) will excite an erythema of the 
skin; the same result follows the application to the surface 
of the aromatic oils and powders, of spirits of turpentine, 
dilute aqua ammonias, the " linimentum cantharidis," and 
many other substances. But the means most commonly 
employed as rubefacients are sinapisms, or poultices made 
of ground mustard-seed. In order to prepare the flour for 
application, it should be mixed with water, and spread 
evenly upon a piece of muslin, having the surface which 
is to be placed next the skin covered with a piece of thin 
gauze or cambric. The efficacy and rapidity of action of 
the sinapism may be increased, by adding vinegar to the 
flour, instead of using water, and also by incorporating it 
with a mixture of oil of turpentine and water. This ap- 
plies only to the white mustard-seed powder. 

The lengih of time during which a sinapism should be 
allow r ed to remain in contact with the skin depends, in a 
measure, upon the sensitiveness of the surface, and the 



OF RUBEFACIENTS. 293 

patient's general sensibility. In the course of a few minutes 
after the application has been made, a sensation of warmth 
is induced, which becomes more and more powerful, so 
that after the lapse of twenty minutes it cannot be tolerated, 
generally, with any degree of comfort. It should now be 
removed, and re-applied at intervals, upon the same part, 
or upon other regions, as may be indicated. If it be suf- 
fered to vesicate the skin, a very troublesome sore often 
results, and sometimes gangrene, from excessive inflamma- 
tion. Attention to the duration of the application is par- 
ticularly necessary when the patient is unconscious, or only 
partially sensible, as the pain arising from the action of the 
mustard, in ordinary circumstances, is not complained of 
now, and great inflammation may be caused before this 
effect is suspected. By combining some other kind of meal 
with that of the mustard seed, a poultice may be made, 
which will excite erythema more slowly, and which may 
be borne upon the skin for a much longer time. 

The ordinary " spice poultice," — made by mixing to- 
gether the powders of several of the aromatics, as cinna- 
mon, cloves, red and black pepper, and mustard seed, 
together with wheat or flaxseed meal, or bread-crumbs 
softened in milk or water, — is an excellent and mild rube- 
facient application. From a half teaspoonful to a teaspoon- 
ful of each of the aromatic powders may be combined with 
a sufficient quantity of one of the other substances to make 
the poultice large enough for the surface to be covered. 

The general stimulant or excitant action of rubefacients 
should be borne in mind when their application is directed, 
as in many cases this influence will be sufficient to counter- 
act their revulsive effect. 



25^ 



294 OF VESICANTS. 



SECTION II. 



OF VESICANTS. 



These are characterized by the effusion of serum beneath 
the cuticle, caused by the inflammation arising from their 
application. Hence, in addition to their derivative effect 
from the diseased organ, and the general excitement which 
they occasion, they act also as depletants : this last pecu- 
liarity serves to counteract the injurious impression which 
would otherwise be incident oftentimes to their stimulant 
action. 

Vesication may be produced by a variety of applica- 
tions. If a very rapid effect is desired, probably the best 
mode is to saturate a cloth, folded to the proper size, in 
boiling water, and lay it upon the surface, taking care that 
the fluid does not flow over a larger space than was in- 
tended. A piece of metal, raised to a high temperature 
by being plunged in boiling water, and then placed in con- 
tact with the skin ; — or, according to the recommendation 
of Carlisle, metal heated to redness and passed over the 
surface, a fold of wetted cloth intervening;- — or a jet of 
steam from the nose of some convenient vessel ; — all these 
are at times resorted to for the purpose of raising a blister 
speedily. But they cause a degree of inflammation which 
often eventuates in gangrene, and are always very painful 
remedial agents. 

There are three remedies of this class which are simple 
in their application and very manageable, and with which, 
probably, the surgeon may accomplish all that he can hope 
to gain from the use of vesicating applications. These 
are the Spanish fly, Croton oil, and aqua ammonias. 



OF VESICANTS. 295 

1st. The cerate made of Spanish flies, — " ceratum can- 
tharidis" of the Pharmacopoeia, — is the preparation which 
is most used. It may be spread on coarse brown paper, 
or on soft leather, or, which is much the most convenient 
and most elegant substance, upon a piece of adhesive 
plaster as it is prepared on sheets of linen for use. In 
covering either of these substances with the cerate, a 
margin should be left all around free from the salve. If 
the adhesive plaster is used, it will be necessary merely to 
warm this margin, in order to make the vesicating agent 
adhere to the skin on which it is placed : if any other sub- 
stance is employed on which to spread the cerate, strips of 
adhesive plaster should be used to retain it on the surface. 

Before applying the vesicatory, the skin should be 
shaved, if there be much hair upon it, and moistened with 
vinegar, in order to increase the rapidity of action of the 
flies ; and it is also advisable to cover the surface of the 
cerate with a piece of fine tissue-paper moistened with 
vinegar, as by this means none of the blistering matter 
will adhere to the skin after the removal of the cerate. 

The length of time during which the application should 
be continued varies with the part to which it is confined, 
the age of the patient, and the state of the general sensibility 
of the individual : probably from two to twelve hours may 
be assumed as the minimum and maximum duration. The 
scalp being much more tardy in responding to the action 
of the vesicant than any other part of the body, the ap- 
plication should be retained longer upon it. It is not neces- 
sary to the formation of the blister that serum should 
actually be effused beneath the cuticle before the vesica- 
ting agent can be removed. If the skin be rendered of a 
bright red colour by the action of the flies, these may be 
withdrawn, and a piece of linen covered with simple cerate, 
or a poultice, may be laid upon it, and in a short time the 



296 OF VESICANTS. 

cuticle will be raised by the serum poured out beneath it : 
excepting in some few cases, where a very powerful im- 
pression is demanded, the desired results will be obtained 
from this course as fully as though the vesicatory had 
been retained upon the part for a much longer time ; and 
this will be found to be the surest way of preventing the oc- 
currence of strangury, one of the most unpleasant incidents 
to the use of the Spanish fly as a blistering application. In 
children this method should always be pursued, the cerate 
being kept upon the skin for two or three hours only, and 
then it will be rare that gangrene, or a very high degree of 
inflammation, will endanger the life which the blister has 
perhaps rescued from the grasp of some formidable disease. 
The mode of dressing the blistered surface will depend 
upon the effect which is desired. If it be not important to 
encourage a continued secretion or discharge from the 
skin, the cuticle should be simply punctured with a needle, 
or with the point of a thumb-lancet, and the serum be suf- 
fered to escape, and simple cerate, or a sofr poultice, be 
subsequently kid upon the surface ; in a day or two the 
irritation will have subsided. But if a continuation of the 
secretion be desired, the cuticle should be removed, having 
been first cut around its adherent edge, and the exposed 
surface of the true skin dressed w T ith basilicon cerate, or 
with savine cerate. If, as is sometimes the case, the sur- 
face be very painful and much inflamed, a soft poultice or 
cold water will be found the best dressing. A sloughy 
condition of the part will be best combated by the appli- 
cation of one of the acids sufficiently diluted, or creasote, 
or decoction of oak-bark, or the solution of Labarraque, 
together with the internal administration of suitable tonics. 
When a blistered surface is tardy in healing, Dr. Wood 
strongly recommends the application to it of " the cerate of 



OF VESICANTS. 297 

subacetate of lead diluted with an equal weight of simple 
cerate." 

Blisters should always be dressed with great gentleness, 
as everv one will feel who has had the misfortune to have 
been blistered. The tearing off the cuticle, recommended 
by some, is a barbarity. 

If strangury should occur, despite the precautions having 
been taken to prevent it, as above recommended, the pa- 
tient may drink pretty freely of flaxseed tea, or if copious 
draughts of liquids be objectionable from particular circum- 
stances, speedy relief will follow an enema of a scruple of 
camphor and twenty or thirty drops of laudanum suspended 
in an ounce or two of water or mucilage. 

The affections strictly surgical, in which blistering by 
this means is most efficacious are, probably, periostitis — 
the blister being produced directly over the seat of pain ; — 
fractures remaining long ununited — where the blister is 
created in order to excite the vessels of the bone and sur- 
rounding soft parts to an increased activity of function, 
with the hope of repairing the injury ; — erysipelas — in order 
to produce a more healthy kind of inflammation, and thus 
to arrest the spread of the disease ; — and gangrene, — the 
object being the same as in the last affection. Besides 
these, many others may be enumerated as being more or 
less benefited by the employment of vesicating remedies, 
such as caries, the various ophthalmic diseases, neuralgia, 
chronic articular inflammations, indolent glandular and 
other swellings. 

The general excitant effect of this class is one of the 
most important therapeutic characteristics, more marked 
in this than in the class last considered. 

2. Croton oil — the " Oleum Tiglii" of the Pharmacopoeia 
— is a very mild and manageable counter-irritant. It is 
more adapted to chronic than to acute diseases ; its general 



298 



OF VESICANTS. 



stimulating effect is much less than that of cantharides, and 
its depleting action is comparatively slight ; as a local de- 
rivative, however, it exerts a decided impression, and this 
may be maintained for a long time with less inconvenience 
to the patient than by the employment of the Spanish fly. 

The effect of Croton oil may be obtained either by fric- 
tions, or by the incorporation of the oil with some sort of 
plaster, so that the compound may be spread upon a suita- 
ble substance, as leather, and worn upon the surface of the 
body. The first is the method usually adopted, as vesica- 
tion is occasioned more speedily by this than by the plaster. 
The oil should be diluted with one or two parts of olive 
oil, or it may be used in its concentrated strength, as the 
skin upon which it is to be rubbed is more or less tender, 
and as a less or more rapid action is desired. It is com- 
mon to moisten a piece of flannel with a few drops of the 
oil, and to rub it over the surface until the skin is decidedly 
reddened and made to smart ; this operation should be re- 
peated after an interval of six or eight hours, and a third 
time, if necessary ; two or three applications will generally 
be sufficient, unless the oil has been much diluted. The 
vesicles are numerous, sometimes coalescing, sometimes 
remaining distinct, each one being surrounded by a red 
areola, which, if the vesicles are near together, give the 
skin a uniform erythematous injection. The fluid is at first 
clear, but soon becomes turbid and puruloid. The irrita- 
tion subsides after a few 7 days, when the application may 
be renewed, if indicated. 

If the other method of employing the oil be adopted, as 
recommended by Dr. Graves, of Dublin, it may be incor- 
porated with lead-plaster, in the proportion of 3j. of the oil, 
to 3ij. or 3iij. of the plaster, and spread upon kid ; or Bur- 
gundy-pitch may be substituted for the lead-plaster. This 
application will produce a vesicular eruption after it has 
been worn upon the surface for a day or two. 



OF VESICANTS. 



299 



In using the Crolon oil, it should be recollected that an 
irritation of the skin will be produced wherever the oil shall 
happen to come in contact with it, as on the eyelids and 
face from accidentally touching these parts with the fin- 
gers on which a little of the oil has remained ; the conse- 
quent burning sensation and swelling are soon relieved by 
the application of cold water. 

3. The strong water of ammonia — "Ammonia? liquor 
fortior," — may be used when a very rapidly vesicating 
agent is needed. It is applied by saturating with it a piece 
of linen folded to the proper size, and laying it upon the 
surface to be blistered, where it should be confined for two 
or three minutes, care being had that the liquid does not 
flow upon the surrounding skin. 

The blistering lotion of Granville contains this prepara- 
tion of ammonia as its active agent. He directs two 
lotions of different powers ; these are prepared thus : 

Strongest water of Am. - - - - - -| and f- 

Distilled spirit of Rosemary - - - - ■§• " f- 

Spirit of Camphor - - -- - - -g- " i" 

" The stronger lotion has been employed by Dr. Gran- 
ville only in cases of apoplexy and for the purpose of cau- 
terization. The first two ingredients are to be gradually 
mixed ; whereupon the mixture becomes opalescent and 
gives out an ethereal smell. Before the addition of the 
third ingredient, the mixture should be rendered transparent 
by means of a little alcohol. These lotions are stated to 
produce as full a vesication in a space of time varying from 
three to ten minutes, as can be produced by cantharides in 
as many hours. They are applied by means of folds of 
linen impregnated with them." (U. S. Dispensatory, art. 
" Ammon. Liq. fort.") 

They are used chiefly to relieve violent neuralgic pains. 



300 OF SUPPURATIVE COUNTER-IRRITANTS. 



SECTION III. 
OF SUPPURATIVE COUNTER-IRRITANTS. 

The remedies of this class act less promptly than rube- 
facients, or vesicants, but when the secretion of pus 
which is excited by them has become established, they 
produce a more depressing effect, inasmuch as the develop- 
ment and continuance of a suppurative discharge involve 
a greater expenditure of vital energy than is called for to 
produce an erythema, or a vesication. Any application 
which will cause a loss of substance of the surface on 
which it is made to act, will occasion suppuration from the 
granulations by which the reparation of the tissues is ac- 
complished. Thus the strong mineral acids, the actual 
cautery, even a vesicant if it produce a sufficiently high 
degree of inflammation, will give rise to suppuration. The 
substances most employed with this view, however, are, 
tartar emetic, caustic potassa, nitrate of silver, the seton, 
the issue, and the moxa. 

1. Tartar emetic is most frequently used in the form of 
the ointment made by incorporating the salt with lard, in 
varying proportions according to the strength required; 
one part of tartar emetic to two parts of lard makes a 
powerful ointment ; a more common proportion is one of 
the former to four, or even eight, of the latter. The strong 
ointment will produce pustulation in the course of a few 
hours. 

The mode of using this agent is, to rub a portion of the 
preparation upon the skin for some minutes, until pain and 
redness are excited ; if a single application be not sufficient, 



OF SUPPURATIVE COUNTER-IRRITANTS. 301 

it should be repeated at intervals of a few hours. Suppu- 
ration from the ulcers thus induced should be favoured by 
dressings of some stimulating cerate, or by poultices. 

A saturated solution of tartar emetic in warm water, to 
be rubbed upon the skin by the aid of a piece of flannel, is 
a very neat and cleanly method of producing pustular in- 
flammation. Another, and a very convenient mode of 
using this agent is, to sprinkle a little of the powder upon 
the surface of a Burgundy-pitch, or other adhesive plaster, 
which is then laid upon the skin and there retained until 
pustules are developed. 

2. Nitrate of silver, commonly called lunar caustic, pro- 
duces an eschar much less deep than tartar emetic, and 
consequently is a less powerful application than the other. 
It is used by moistening a stick of the caustic and rubbing 
it upon the skin. As a caustic, it is employed to cause a 
superficial slough which, when it has become detached, 
leaves a healthy granulating surface, as in the treatment 
of chancre, and old ulcers. 

3. Caustic potassa, prepared in the form of " sticks," is 
a much more effectual pustulating application than the 
last. With this, the tissues may be destroyed to almost 
any extent and depth, and great care is therefore neces- 
sary in making use of it. The best and safest plan is, to 
lay upon the skin a piece of kid in which a hole is cut 
corresponding in size and situation with the portion of the 
skin on which the caustic is intended to act; then the 
potassa slightly moistened is to be placed, or rubbed, upon 
the skin thus exposed, until a sufficiently thick eschar is 
produced, after which it is advisable to pour a little vinegar 
upon the part, in order to render inactive any portion of 
the caustic which may still adhere to the tissues. The 
separation of the slough, thus produced, should be hastened 
by the application of warm poultices, and the granulating 

26 



302 OF SUPPURATIVE COUNTER-IRRITANTS. 

surface, left exposed after the detachment of the eschar, 
should be dressed with slightly stimulating lotions, or 
cerates, to encourage the secretion of pus. 

The " Vienna paste," recommended by surgeons on the 
continent of Europe, is made by triturating together, with 
the aid of a little alcohol, five parts of caustic potassa and 
six parts of quick-lime. The compound is used in the 
same manner as the caustic potassa alone, and produces 
an eschar in a few minutes, w 7 ith less pain than the other. 

A paste, made by incorporating chloride of zinc with 
wheat flour and water, is recommended by many surgeons 
as a caustic. M. Canquoin prepares it of different strengths, 
according to the desired effect; thus he triturates one part 
of chloride of zinc with two, three, four, or five parts of 
flour, adding fifteen drops of water for every ounce of the 
flour. The paste thus formed is divided into cakes, vary- 
ing in thickness from one-twelfth to one-third of an inch, 
and applied to the part; the eschar which it causes may 
be from one line to an inch and a half deep, according to 
the thickness of the portion of caustic, the duration of its 
application, and the character of the tissue to w 7 hich it is 
applied. (U. S. Dispens.) 

The white oxide of arsenic is now rarely used as a 
caustic : its application is generally attended with great 
pain, and unpleasant constitutional effects have often fol- 
lowed it. 

Iron heated to w r hiteness has been, in earlier times, much 
resorted to as a means of producing a slough and subse- 
quent suppuration. It is now, however, seldom employed 
for this purpose. When used thus, the iron is called " the 
actual cautery" in contradistinction from the other caustics, 
to which the term, 'potential cauteries, has been applied. 

4. The moxa, as it is ordinarily used, consists of a cylin- 
der of carded cotton, about an inch long and from one to 



OF SUPPURATIVE COUNTER-IRRITANTS. 303 

two inches in diameter, the whole wrapped in a piece of 
linen and impregnated with a saturated solution of nitrate 
of potassa, or of chromate of potassa. To apply it, one 
of the extremities of the cylinder should be lighted in the 
flame of a lamp, and the other placed upon the skin, the 
roll being beheld between the blades of a pair of dressing- 
forceps. The moxa is maintained in a state of ignition by 
blowing upon it with the mouth, through a blow-pipe, or 
with the lips merely, the object being to secure a steady 
heat. The pain experienced from this application becomes 
gradually more and more severe, until the sensitive struc- 
ture of the skin is destroyed, when it ceases. A thick eschar 
is thus formed, which, by the continued application of emol- 
lients, becomes detached after some days, leaving a granu- 
lating, suppurating surface, requiring dressings suitable for 
such a condition. 

The moxa is generally employed as a counter-irritant in 
diseases of the bones, as caries of the spine, and is applied 
near to the seat of the affection, — not so near, however, as 
to involve the vessels and nerves in the slough which is 
formed. 

5. Issues are established by the introduction into the sub- 
cutaneous tissue of some foreign body which acts as an 
irritant, and thus perpetuates a suppurative secretion. The 
substance generally used for this purpose is made of cork, 
or pine wood, or indeed of any similar material, cut to 
about the size and shape of the common garden-pea. It is 
introduced into the tissue either by an incision made with 
the knife, or it may be confined by means of strips of ad- 
hesive plaster upon the granulating surface, produced by 
the action of caustic potassa or a vesicating agent. 

There is some choice as to the point at which the issue 
should be established ; it may be directly over the seat of 
the disease, or, if this be not important, at some remote 



304 OF SUPPURATIVE COUNTER-IRRITANTS. 

point. The arm and the back of the neck are the most 
convenient situations for the formation of an issue ; in the 
former, the pea should be introduced in the space between 
the biceps and deltoid muscles, near the insertion of the 
latter. When the neck is selected, any point may be taken 
which seems most convenient ; it should generally be low 
down, so that the patient's dress may conceal it from view. 
6. Setons are established by passing a piece of tape, or 
a skein of silk, or other similar material, through a portion 
of the integuments, and leaving it to excite suppuration. 
The seton may be introduced by means of the instrument 
contrived by Boyer for the purpose, — a blade shaped some- 
what like that of the thumb-lancet, but stronger and curved 
also, and having an eye cut in its heel, through which the 
seton-tape or silk is passed; — or it may be effected simply 
by using a common bistoury and an eyed-probe. In either 
case, the first step of the operation is the same : a fold of 
the integuments is pinched up between the thumb and fore- 
finger of the left hand, and the blade of the instrument, 
previously oiled, — be it the seton-needle, or the bistoury, — 
is thrust through its base ; if the seton-needle is used, it 
should be armed with the tape or silk, and drawn through, 
its armature following; if the bistoury is employed, the 
probe is armed in the same way, and passed along the base 
of the wound upon the blade. After the needle or the 
probe has thus cleared the incision, it is disconnected from 
the seton, and the extremities of the latter are tied together, 
forming a loop which encloses a portion of the integu- 
ments ; a poultice should be laid upon the wound, and re- 
tained in place by a proper bandage, for a few days, until 
suppuration has become established, when simple cerate 
may be substituted as a dressing, and confined by adhesive 
strips. The seton should be drawn daily backwards and 
forwards across the wound, in order to stimulate the latter 



OF ACUPUNCTURE. 305 

slightly, and to sustain the discharge ; and once or twice 
every week a clean seton should be introduced, by attach- 
ing one end of it to one of the extremities of the tape 
already in use, and drawing it within the wound. 

Any part of the surface of the body may be selected for 
the establishment of a seton, — the blood-vessels and nerves 
being avoided, of course, — but the back of the neck is 
usually chosen as being the most convenient part. 



ACUPUNCTURE. 

For convenience-sake, the modes of practising acupunc- 
ture and vaccination will be considered in connexion with 
this chapter, although neither of these operations are per- 
formed with a view of effecting cutaneous irritation merely. 

Acupuncture. — The instrument by which this is accom- 
plished is a needle about two inches long, having a cylin- 
drical shaft tapering towards one extremity to a sharp 
point; the other end is received into a small handle of 
ivory or of steel, or it is simply coated with sealing-wax. 
The needle is made sometimes of steel, sometimes of one 
of the precious metals. In introducing it, the instrument 
is held perpendicularly upon the surface, and forced through 
the skin to the requisite depth by a rotatory movement, 
combined with a sufficient pressure upon the point. The 
punctures are made in muscular, tendinous, or aponeurotic 
tissues, whichever may be the seat of suffering, and the 
depth of the puncture must of course depend upon the po- 
sition of the tissue affected. It is advisable to allow the 
needle to remain in the part for a length of time, as for a 
half hour, an hour, or even longer, since a more perma- 
nently beneficial effect is thus produced than when the in- 
strument is withdrawn at once. The needle may be ex- 

26* 



306 OF VACCINATION.' 

tricated, by making slight pressure upon the surface, and 
withdrawing the instrument with a rotatory movement. 

No accident follows the operation, generally; rarely 
more than a drop of blood appears at the puncture ; the 
chief vessels and nerves are always avoided, and the punc- 
ture should not penetrate any of the important cavities, or 
viscera. 

Electro-puncture consists in passing through needles, in- 
troduced as above described, a current of electricity col- 
lected in a Leyden jar, or generated in a small voltaic pile, 
which is connected with the needles by a metallic wire 
passing to each pole of the battery. 

Both these varieties of acupuncture are frequently of ser- 
vice in the treatment of neuralgia, and of rheumatism un- 
attended with inflammation ; in the treatment of indolent 
tumours also, by promoting their removal by absorption ; 
in the cure of local paralysis, &c, &c. Simple acupunc- 
ture is very often resorted to in order to evacuate anasar- 
cous collections. 

Local pain of a violent neuralgic character may be re- 
lieved in many instances, and speedily, by rubbing upon 
the surface thus punctured a solution of sulphate of mor- 
phia, containing several grains in each ounce of water. 



VACCINATION. 

The operation, as generally practised, consists in insert- 
ing beneath the cuticle at some convenient point the matter 
of the cow-pock. 

Several methods have been adopted for the collection 
and preservation of vaccine matter. If it were practicable, 
the simplest method would be, to transfer the liquid vac- 
cine lymph from the arm of one child to that of another — 



OF VACCINATION. 307 

upon whom the operation is about to be performed. But 
since this proceeding is not always convenient or possible, 
the virus must be collected and preserved in the liquid state, 
or in the form of the dry crust. In the liquid state, it may- 
be preserved between two small plates of glass. Or capil- 
lary tubes, having a bulb at one extremity, may be placed 
in contact, at the open end, with the lymph of the fifth or 
sixth dry vesicle, — the air in the bulb having been rarefied 
by the warmth of the hand, or of the mouth, is again per- 
mitted to cool and contract, when the fluid will enter; so 
soon as a sufficient quantity has collected in the bulb, the 
extremity of the tube should be sealed in the flame of a 
spirit-lamp and blow-pipe. But the most convenient method 
to be pursued in the preservation of the virus is, to permit 
the lymph to dry, either on points of ivory, or as a scab 
upon the surface at the site of the vaccination. If the latter 
be adopted, the crust may be very well kept by being en- 
veloped in tin-foil, or between two pieces of wax excavated 
to receive it. The author has recently vaccinated several 
children with a scab which has been thus preserved for 
two years ; the vesicle was developed in each case, and 
passed through its customary phases with perfect regu- 
larity. 

The operation may be performed with a thumb-lancet, 
or with a lancet made expresly for vaccinating ; this dif- 
fers from the thumb-lancet only in being smaller. The 
virus may be introduced beneath the cuticle, by means of 
lateral punctures made with the point of the lancet ; or, the 
skin having been rendered tense between the thumb and 
forefinger of the left hand placed upon the part of the sur- 
face selected for the seat of the operation (generally the 
arm above the elbow), the cuticle may be removed, over a 
minute space, by slight scratches with the point of the 
lancet, crossing and recrossing each other until the vascu- 



308 OF VACCINATION. 

lar surface is reached, (blood being just made to appear,) 
and then the virus be applied thereon. If the liquid lymph 
be used, it is simply requisite to moisten the lancet there- 
with, and to apply the blade upon the exposed surface ; if 
the points of ivory be employed, one of them may be in- 
serted beneath the cuticle, according to the first method of 
operating, or placed in contact with the denuded surface, 
if the second plan be adopted ; if the scab be selected, a 
small particle of it should be reduced to powder and mois- 
tened with a little water, being rubbed to a pulpy consis- 
tence by the aid of the lancet-blade, which should now be 
wiped upon the abraded skin, so that a sufficient portion of 
the vaccine matter shall come in contact with the absorb- 
ing surface. After the operation is completed, the part 
should be left uncovered until the surface has become per- 
fectly dry ' r the subsequent stages which the vaccine dis- 
ease assumes, in the development and maturation of the 
vesicle, should be carefully watched, in order that a correct 
opinion may be had as to the efficacy of the operation. 



CHAPTER III. 

ON THE METHODS OF ARRESTING HAEMORRHAGE. 

The occurrence of bleeding, as an accident, or in con- 
nexion with an operation, always claims the prompt atten- 
tion of the surgeon, and often demands the manifestation of 
all his skill and self-possession. 

In the consideration of this subject we shall describe the 
methods found most efficacious in arresting hemorrhage, 
and state the circumstances to which each is most ap- 
plicable. 

1. By the action of cold. This is the simplest method 
of arresting the flow of blood from a wound, and its efficacy 
is exemplified daily, the mere evaporation which takes 
place at the surface of the wound reducing the temperature 
of the part, thereby favouring the coagulation of the blood 
and exercising a degree of constriction upon the bleeding 
vessels. This effect may be increased by exposing the 
divided tissues to a current of air, naturally or artificially 
excited. Bleeding from superficial wounds, or abrasions, 
when no vessel of notable size is opened, may generally be 
checked by this simple mode. 

The application of cold water, or of ice, to the bleeding 
surface, or to its immediate vicinity, is still more effectual, 
and will very often arrest hemorrhage from small arteries. 
Dr. G. N. Burwell, of Buffalo, informed the author very 
recently, that he had succeeded in stopping profuse bleed- 
ing from a deep transverse wound of the palm of the hand, 



310 ON THE METHODS OF ARRESTING HEMORRHAGE. 

by the constant application of ice during twenty-four, or 
thirty-six hours. The ice may be placed in direct contact 
with the wound, or it may be enclosed in linen, or in a 
bladder. If cold water is used, it may be simply laid upon 
the surface in saturated lint, or it may be employed by 
douche, or irrigation ; the latter is the most efficacious. 
Evaporating lotions may be found effectual sometimes, in 
the absence of ice. 

2. By the application of astringents, and styptics. These 
act, probably, in a twofold manner, — upon the organic 
properties of the bleeding vessels and surrounding tissues, 
and also upon the blood itself; causing by the former, a 
constriction, a greater or less degree of closure, of the 
vessels, — and by the latter, favouring coagulation of the 
effused blood which mechanically prevents the escape of 
more. There are many substances which induce coagula- 
tion of blood, not by any chemical, or vital, agency which 
they exert, or develope, but simply by opposing the flow at 
numerous points, so that it becomes retarded, and then 
coagulates by its own inherent properties ; such are cob- 
web, filaments of lint, powdered sugar, and other similar 
domestic remedies. 

The astringent and styptic applications which have been 
found most serviceable for the purpose under consideration 
are, powdered alum ; powdered galls ; sulphate of copper 
and of zinc, also in powder ; creasote, and the tincture of 
the muriate of iron. Fluids act most rapidly because they 
come most speedily in contact with the points from which 
the blood escapes; they are applied usually by means of 
a brush of camel's hair, or upon a feather, passed over 
the surface ; or by saturating with them a piece of lint 
which is pressed lightly upon the part. If a powder is 
used, it may be sprinkled over the surface, or retained upon 
it by gentle pressure. The tincture of the muriate of iron 



ON THE METHODS OF ARRESTING HEMORRHAGE. 311 

is probably the best of these means. These agents will 
generally suffice to arrest bleeding from vascular surfaces, 
no large vessel being opened, — for example, in haemorrhage 
from the mucous membrane lining the nostrils, in bleeding 
ulcers on the neck of the uterus, in bleeding haemorrhoidal 
tumours. 

Matico, a plant growing in South America, has been 
lately recommended as possessed of particular efficacy in 
arresting haemorrhage. Dr. Ruschenberger, of the U. S. 
Navy, has employed it in a large number of cases and 
bears strong testimony to its value as a haemostatic agent. 
He used it successfully to arrest bleeding from a bubo 
which had been opened by the knife, and from which the 
blood issued in full and free jets, long-continued and well- 
applied pressure having failed to arrest it ; it likewise 
caused the cessation of bleeding from haemorrhoids removed 
by incision, which had produced troublesome haemorrhage, 
resisting other applications of various kinds. The mode 
which Dr. Ruschenberger advises for its employment is, to 
break the dried leaves into a coarse powder and to form 
with this, by the aid of water, a pultaceous mass, which 
should then be placed upon the bleeding surface and re- 
tained there by very light pressure, — a pressure which 
would not prove sufficient, of itself, to arrest the bleeding. 
Dr. R. speaks highly of the efficacy of matico, taken in in- 
fusion, for spontaneous haemorrhage, having proved its 
value in profuse menorrhagia, in haemophthisis, and similar 
cases. 

3. By cauterization. This produces an eschar, sealing 
up the orifice, or orifices, from which the blood escapes. 
So long as the eschar remains adherent to the vessel, it 
presents a mechanical impediment to the further escape of 
blood ; but when, in the process of nature, the slough has 
become detached, the haemorrhage will recur, unless the 



312 ON THE METHODS OF ARRESTING H-EMORRHAG-L 

vessel has become permanently obliterated from its open 
extremity as high up as the first branch above it ; hence 
the patient should be carefully watched about the 
time at which the slough seems inclined to separate, lest 
the bleeding should return unexpectedly. In the choice of 
a cauterizing agent, therefore, some one must be selected 
which shall produce an eschar sufficiently deep to remain 
adherent, until nature shall have accomplished the perma- 
nent closure of the vessel between the points mentioned. 
The fact should be borne in mind that, the application of 
any caustic will prevent the possibility of union of the 
wound by the first intention. The actual, or the potential 
cauterv. mav be used. 

In employing the actual cautery, the metal, generally 
iron, should be heated to whiteness and then applied upon 
the surface for a few seconds only ; both of these precau- 
tions are necessary, for if the iron be of a lower tempera- 
ture than that which constitutes * white heat,' the eschar 
occasioned by it is less perfect and its action is more pain- 
ful ; and if the cautery be kept too long in contact with 
the tissues, it adheres to them, and when it is withdrawn, 
it removes the eschar with it, thereby destroying, of itself, 
the good which it had accomplished. 

The form of the cautery should be adapted to the cha- 
racter of the part to which it is to be applied : thus, if the 
wound be narrow, and the bleeding vessel lay at the bottom 
of it, the iron should be sufficiently long and small to reach 
to the orifice of the vessel. The annexed drawing illus- 
trates some of the most common forms of the actual cau- 
tery. (Fig. 100.) 

The actual cautery is now rarely used to arrest haemor- 
rhage, this object being almost always etfected by some 
other means more simple, and less shocking in appearance. 
The cases in which it is still recommended are, in opera- 



ON THE METHODS OF ARRESTING HEMORRHAGE. 313 

tions upon the bones of which the medullary membrane is 
excessively vascular ; in the bleeding which sometimes fol- 
lows the extraction of a tooth, and in others similar. 

Fig. 100. 



Of the potential cauteries, those most used are, the nitrate 
of silver, and concentrated sulphuric acid. The former may 
be employed in the solid state, its extremity having been 
previously more or less pointed, by friction upon the sur- 
face of a wet rag, or in concentrated solution, as of Bj to 
a fluid-ounce of water, applied, as is the acid, by means of 
a brush. The efficacy of lunar-caustic, in stick, in arrest- 
ing bleeding from leech-bites, has already been mentioned. 
The solution of the salt, or the sulphuric acid, is often of 
service in haemorrhage from incised or ulcerated surfaces, 
which are too much removed from sight to admit of nice 
inspection and handling, and from those which present no 
apparent vessel, or bleeding point : thus bleeding ulcers or 
wounds on the neck of the uterus are sometimes treated, a 
speculum vaginae being used to assist the surgeon in the 
application of the remedy. 

4. By directly obliterating the vessel which gives out the 
blood. This may be a temporary or a permanent effect, 
as the means used are temporary or permanent in their 
action. Transient obliteration may be best induced by 

27 



314 ON THE METHODS OF ARRESTING HEMORRHAGE. 

simple pressure upon the vessel ; permanent occlusion is 
produced by torsion, and the use of the ligature. The for- 
mer is applicable to all varieties of accidental bleeding, 
"whether it be arterial, venous, or capillary; the ligature 
and torsion are employed almost exclusively in arterial 
haemorrhage. 

Pressure. — The mode of making the requisite compres- 
sion varies according to circumstances. 

If there be a wound bleeding moderately, or if the blood 
be of a venous character, it very often happens that the 
haemorrhage is arrested by the mere apposition of the 
edges of the wound, if it be an incised wound ; or by the 
simple pressure upon it of the dressings, if it be such as 
not to admit of apposition of its lips. When the divided 
vessels are of a larger calibre and bleed more freely, pres- 
sure should be made with the aid of a compress and adhe- 
sive plaster, or a roller. Direct pressure upon a wound is 
objectionable, particularly if it be a lacerated or contused 
wound, or if much pressure be required to produce the de- 
sired effect, because it will interfere with the reparation of 
the injury, and may induce sloughing. When positive 
pressure is to be exerted for the sake of the compression, 
the vicinity of the wound should therefore be selected as 
the site of its application, rather than the wound itself. 

Pressure is employed also to prevent haemorrhage during 
operations, as in amputations, and likewise in accidental 
wounds, as a temporary expedient, until some more per- 
manent measure be adopted. For this purpose, the com- 
pressive force may be applied at any point at which it can 
be most effectually and conveniently exercised. The sim- 
plest method of instituting this measure, is to press the fin- 
gers upon the course of the vessel through which the cir- 
culation is to be arrested. With this object, some point 
should be selected where the vessel is readily felt pulsating ; 



ON THE METHODS OF ARRESTING HEMORRHAGE. 



315 



and, if possible, this point should be favourably situated with 
regard to some bony support, so that the vessel can be 
pressed against the latter, and thus be completely oblite- 
rated. For example, the facial artery should be compress- 
ed against the edge of the lower jaw, at the anterior mar- 
gin of the masseter muscle ; the temporal and occipital 
arteries, at any point of their course, at which they can be 
felt; the brachial artery, by grasping the biceps muscle, at 
the middle of the arm, between the fingers and thumb of the 
right hand, and at the same time pressing the artery against 
the bone with the points of 
the fingers, on the inner side lg ' ' 

of the muscle, (fig. 101 ;) the 
axillary artery, by thrust- 
ing the fingers, — their points 
approximated, — into the ax- 
illa, and forcing the artery 
against the head of the hu- 
merus; the subclavian ar- 
tery, by pressing the thumb 
down upon the vessel, be- 
hind the clavicle, upon the 
point at which the artery 
crosses the first rib on the 
external side of its tubercle; 
generally, the artery cannot 
be sufficiently well com- 
pressed by the thumb, and 
it is necessary therefore to 

employ some instrument for the purpose, as a common door- 
key, of which the ring should be wrapped with a piece of 
linen, and then pressed upon the vessel, as above advised ; 
the femoral artery, by placing one thumb upon the vessel, 
at the point where it crosses the ilium to descend the thigh, 




316 



ON THE METHODS OF ARRESTING HEMORRHAGE. 



Fl £- 102 - and making the requi- 

site pressure by the other 
thumb acting upon the 
first, (fig. 102;) the ab- 
dominal artery, by caus- 
ing the patient to occupy 
a position whereby his 
back and thighs shall be 
flexed, and the abdomi- 
nal parietes relaxed, and 
then pressing the artery 
against the spinal column. 
But, although it is not 
necessary, in most cases, 
to exert much force with 
the fingers, the muscles 
are very soon fatigued, 
so that the pressure be- 
comes unsteady and un- 
certain, if it be maintained for any length of time ; and 
moreover, the fingers are liable to become displaced by 
any sudden movement of the patient ; hence the neces- 
sity of employing some compressing force which shall not 
be liable to these objections. The tourniquet offers such 
advantages. 

The tourniquet, in its most perfected form, is very well 
represented in the annexed drawing, (fig. 103.) It is so 
contrived, that when the strap is buckled around the limb, 
by turning the screw the soft parts are compressed and 
the pad forced upon the artery. Before applying the tour- 
niquet, the surgeon should examine it carefully, to see that 
it is in good order, — the screw, strap and buckle strong, — 
so that it shall not fail when most needed. A firm pad 




ON THE METHODS OF ARRESTING HAEMORRHAGE. 



317 



Fig. 103. 




should be made, of a cylindrical shape, for application over 
the artery, and the strap secured around the limb. The 
screw should not be turned too rapidly, and no more com- 
pression should be exercised about the limb than may be 
necessary to prevent the flow of blood below the point of 
pressure. A long-sustained application of this instrument 
is productive of considerable pain, and therefore it should 
be avoided. 

The points upon which the tourniquet is applied to the 
limbs are not fixed. Mr. Fergusson recommends those 
indicated in the accompanying drawings, (figs. 104, 105, 
106,) preferring compression of the artery in the popliteal 
region, when the leg is to be amputated below the knee, 

27* 



318 ON THE METHODS OF ARRESTING HEMORRHAGE. 

rather than of the femoral artery at the upper part of the 
thigh. 



Fig. 104. 



Fig. 105. 




Fiff. 106. 




ON THE METHODS OF ARRESTING HAEMORRHAGE. 



319 



Fig. 107. 



An * impromptu' tourniquet, for use in emergencies, con- 
sists of a cravat, in the middle of which a knot is formed ; 
the cravat is made to encircle the 
limb, the knot corresponding in 
situation with the artery : the two 
extremities are then tied together, 
a piece of stick inserted between 
them and made to revolve until 
the limb is sufficiently compressed. 
This is commonly called the field- 
tourniquet, (Fig. 107.) 

An objection to the tourniquet 
is, that it constricts the whole 
limb, preventing the circulation 
through the veins as well as through 
the arteries, causing considerable 
pain and swelling, if continued 
beyond a short time. To obviate 
this difficulty, compressing instru- 
ments of various kinds have been 
invented : they have not, as yet, arrived at such perfection 
as to be on the whole preferable to the tourniquet in com- 
mon use. The compressor of Dupuytren " consists of two 
steel-plates, (fig. 108,) half an inch broad, curved and 
joined at the centre of the instrument in such a manner as 
to allow of the curve being increased or diminished at will. 
To these plates two others which support pads are at- 
tached : one of the pads is movable, the other fixed ; and in 
applying the instrument the movable one is placed over 
the artery, the other rests upon the opposite side of the limb. 
The pressure is made by the movable pad and is regulated 
by a screw." (Liston's and Mutter's Lectures on Surgery, 
p. 42.) 

Dr. Dorsey, (Elements of Surgery, vol. i. p. 57,) mentions 




320 



ON THE METHODS OF ARRESTING HEMORRHAGE. 



Fig. 108. 



a very simple and inge- 
nious expedient by which 
the same effect was at- 
tained. " The patient was 
a child in whom several 
unavailing attempts had 
been made to tie up the 
divided vessel, (an artery 
in the foot,) and the wound 
was in a state of great 
inflammation. A com- 
press was applied over 
the trunk of the anterior 
tibial, and another over 
that of the posterior tibial 
artery, about two inches 
above the ankle; over 
these a strip of sheet cop- 
per was passed around 
the leg, and a tourniquet applied over the copper : when 
the tourniquet was tightened, the tibial arteries were com- 
pressed and the bleeding ceased, the copper preventing the 
tourniquet from compressing any other vessel, so that the 
circulation in the foot was not interrupted. In a few days 
the wound healed without any recurrence of hemorrhage." 
Plugging of the divided vessel, or of a wound, is some- 
times resorted to for arresting the flow of blood when other 
means have failed. It acts by compressing the vessel, or 
by mechanically stopping its orifice. It is rarely done now, 
excepting occasionally when blood continues obstinately to 
flow from the cut extremity of the bones in amputation: 
here a piece of lint, having a ligature attached to it, is 
gently pressed within the cavity of the bone, or within its 
retieulated structure, and allowed to remain, the ligature 




ON THE METHODS OF ARRESTING HEMORRHAGE. 321 

hanging from between the edges of the flap, so that the 
plug may be removed when it has fulfilled its intention. 

Torsion is now but little resorted to. It consists in twist- 
ing the vessel several times upon its axis, so as to rupture 
its inner and middle coats, which then become F . 109 ^ 
more or less inverted, as when cut by a liga- 
ture. Many methods of performing this 
simple operation have been advised, of which 
the simplest is probably as effectual as any. 
The artery should be seized at its open extre- 
mity by a pair of toothed forceps, (fig. 109,) 
with which it is drawn out from the wound, 
and isolated from its connexions with the sur- 
rounding tissues ; it is then held in the grasp 
of a pair of dissecting forceps placed across 
its axis, at the distance of half an inch from 
its open end, and twisted several times in the 
direction of its axis by means of the first for- 
ceps: the torsion having been thus accom- 
plished, the vessel is returned into the wound. 
This is not generally trusted to as a safe and certain means 
of arresting haemorrhage, excepting in the instance of small 
arteries. If the vessel can be thus seized and twisted, a 
ligature can certainly be applied to it as well, and will 
scarcely give rise to more irritation than the portion of the 
artery thus violently crushed and reduced to the condition 
of a foreign body in the wound. 

The ligature offers the most safe and permanent means 
of obliterating an artery of a size sufficient to admit of its 
application. 

The object had in view in the employment of the ligature 
is, the division of the internal and middle coats of the artery; 
these retract within the canal, giving the latter the appear- 
ance of a cone, of which the apex points towards the 



322 ON THE METHODS OF ARRESTING HEMORRHAGE. 

ligature. The cavity of the vessel, from the ligature to the 
first branch above it, becomes filled with a coagulum of 
blood, and the same coagulating process takes place in the 
blood which has been effused outside of the vessel ; soon, 
however, a permanent obliteration occurs, from a vital 
process, some degree of inflammation and exudation of 
plastic matter being occasioned by the irritation of the 
ligature, and a complete consolidation of the tube ensuing 
from union of the internal tunic of the artery with the 
organizable mass within it. 

Many substances have been recommended as materials 
for the ligature. It has been supposed that leaden ligatures 
excite less irritation in the midst of the tissues than those 
of any other material ; ligatures made of animal fibre, as 
of the sinew of the deer, have been supposed to be re- 
moved by absorption at the point at which they are tied ; 
but these are probably mistaken ideas ; no one now thinks 
it advisable to incur the trouble of preparing ligatures of 
such materials, for the sake of any advantage which fancy 
may attribute to them over the ordinary ligature, made of 
saddler's silk, or of common flaxen thread. 

A single strand of strong saddler's silk, or of good home- 
spun thread, will answer for application to small arteries ; 
but when the vessel is larger, the ligature should be cor- 
respondingly more thick, as of from two to four strands. 
These should be well waxed, and twisted firmly and 
roundly, in order to cut the coats of the artery, as before 
mentioned, a flattened ligature not effecting this object. 
Hence also in applying the ligature, the knot must be 
drawn tightly. For the purpose of seizing the artery, in 
order to isolate and tie it, the forceps above recommended 
and figured (see fig. 109), having a toothed extremity and 
a spring-catch to keep this closed, is a very convenient 
instrument, less so, however, than the tenaculum (fig. 1 10) — 



ON THE METHODS OF ARRESTING HEMORRHAGE. 



323 



Fig. 110. 



a hook with a long curve sharp at the point 
— which is inserted into the mouth of the ves- 
sel, and by which the latter is drawn out. 
The artery being thus brought within reach, 
it should be separated from its connexions 
with the surrounding tissues, vessels, and 
nerves, for the space of a few lines, and the 
ligature applied around it, behind the tenacu- 
lum, or forceps. It is sometimes proper to 
include a portion of the surrounding tissues 
in the knot, as when the coats of the artery 
are supposed to be weakened from inflamma- 
tion or other cause, or when the mouth of the 
vessel which bleeds cannot itself be seen, and 
yet the surgeon is assured that it is within the 
mass which he has raised upon his tenacu- 
lum, or by his forceps. If an artery of con- 
siderable size has been divided, it is advi- 
sable to tie both extremities, as otherwise the bleeding may 
be renewed from that portion of the vessel which was not 
at first emitting blood, but into which an anastomosing cur- 
rent has afterwards discharged itself: this precaution is 
particularly necessary in situations where the anastomosis 
of arteries is known to be common, as in the palm of the 
hand and on the foot. 

" The sailor's knot," as it is 
called, is the one best calcu- 
lated to secure the artery 
firmly ; it forms, when tightly 
drawn, a flat knot which will 
not slip. The accompanying 
drawing illustrates it better 
than a verbal description. 
(Fig. 111.) 



Fig. 111. 




324 ON THE METHODS OF ARRESTING HAEMORRHAGE. 

The vessel having been tied, one division of the ligature 
should be cut off close to the knot, while the other is left 
hanging from the wound. When many vessels have been 
tied, the ligatures thus cut should be grouped together and 
allowed to project at one extremity of the wound, of which 
the edges should then be approximated : when one of the 
vessels tied is of large size, as the main artery of a limb, 
the ligature which is attached to it should be indicated by 
a knot made at its free extremity. 

The length of time during which the ligature remains 
connected with the artery, varies according to the size of 
the latter ; generally, from five to twenty days may be con- 
sidered as elapsing before the external coat of the vessel 
becomes severed at its point of constriction ; then the liga- 
ture is loosened and falls from the wound, or may be 
readily drawn from it. After the usual time has passed, 
the ligature may be gently twisted and drawn upon, in 
order to favour its release, as sometimes it is retained by 
the granulations in which it is imbedded, after its attach- 
ment to the vessel has ceased. The ligature appertaining 
to the largest vessel should be handled more carefully than 
the others. The patient should be carefully watched about 
the period at which the ligatures become detached, parti- 
cularly when large vessels have been tied, lest an unex- 
pected haemorrhage occur. Secondary bleeding requires 
the same treatment as the primary. 

The forceps and tenaculum are the only instruments re- 
quired for tying a vessel which presents itself at the sun- 
face of a wound. But it often happens that the bleeding 
artery cannot be seen, it having retreated within the sub- 
stance of the tissues : it then becomes necessary either to 
slit open the tissues from the point at which the haemorrhage 
appears, or to cut down upon the course of the vessel above 
the wound, and pass a ligature around it at this point ; the 



ON THE METHODS OF ARRESTING HEMORRHAGE. 325 

former is a very uncertain and disagreeable operation, the 
latter is speedy, simple, and sure. The incision having 
been made at the point at which the vessel is most acces- 
sible, the object is to inclose the latter in. the loop of a 
ligature without including the accompanying vein or nerve. 
To enable the surgeon to effect this, several instruments 
have been contrived, to which the term aneurism-needles 
has been applied. The simplest, and one which answers 
very well almost always, is shown in the annexed draw- 
ing (fig. 112) ; it needs no farther description. When the 

Fi ff . 112. 




sheath of the vessels has been opened, the extremity of this 
needle, armed with a ligature, is carried under the artery 
and brought out on the opposite side, when one division of 
the ligature is seized between the fingers, or by a forceps, 
and drawn out upon one side, while the other portion fol- 
lows the needle as it is removed at the other side of the 
wound: the vessel is then tied, as above advised. Professor 
Gibson has invented an admirable instrument for passing 
a ligature beneath deep-seated arteries. It consists of a 
flattened canula of silver sufficiently strong, curved rather 
more than the common aneurism-needle figured above, and 
fitted to a handle ; through the interior of the needle, of 
which one extremity of the cavity opens near the handle 
on the back of the needle, and the other at the point, a piece 
of watch-spring passes, having an eye at the extremity 
nearest the handle, and terminating at the other end in a 

28 



326 



ON THE METHODS OF ARRESTING HEMORRHAGE. 



head of silver; the ligature is placed in the eye of the 
spring, and the needle is passed beneath the artery ; then 
the spring, which is considerably longer than the needle, is 
pushed through the cavity of the instrument and appears 
upon the opposite side of the vessel, carrying the ligature 
with it. Belloc's instrument, illustrated by fig. 115, would 
answer very well in many cases where the artery is 
deeply located. But in the majority of instances, a liga- 
ture can be readily passed around a vessel by means of the 
grooved director and the eyed-probe, which are in every 
one's pocket-case. The director is introduced beneath the 
vessel, and carried completely across the wound so as to 
rest upon the edges of the latter, the artery being raised 
upon it; then the probe, armed with the ligature, is slid 
along the groove of the director, beneath the artery, and 
drawn out upon the opposite side with the ligature. In 
some instances, the bleeding artery is concealed behind a 
projecting bone, as, for example, the internal pudic behind 
the rami of the ischium and pubis; in order to secure this 
vessel, Dr. Physick's forceps, having a curved needle in- 
serted between its blades, and furnished with a hook to 
compress its handles, will be found the most convenient 
instrument. (Fig. 113.) 

Fig. 113. 




The surgeon is sometimes called upon to arrest hemor- 
rhage from one of the natural canals, or cavities, particu- 
larly from the nostrils and rectum. 

Epistaxis occurring in individuals of a hemorrhagic 
diathesis, frequently induces a dangerous degree of pros- 
tration. If it resists the use of cold water, or ice, applied 



ON THE METHODS OF ARRESTING HEMORRHAGE. 



327 



upon the face and forehead, or on the back of the neck, 
and if astringent powders blown into the nostrils, or injec- 
tions of astringent solutions, fail to arrest it, the nostrils 
must be plugged. Stopping the anterior orifices of these 
cavities will not suffice, as the blood will continue to escape 
through the posterior nares ; both must be stopped there- 
fore. To effect this, a piece of thin wire may be doubled 
upon itself, and the folded end introduced along the floor 
of the nostril, from before backwards, until it has traversed 
the passage and appears at the back part of the mouth ; 
the surgeon then seizes this looped extremity with his fin- 
gers, or forceps, introduced into the mouth, draws it for- 
wards, — the bodv of the wire still resting on the floor of 
the nostril, — and passes a cord through it, the centre of 
the cord corresponding with that of the loop, while the 
ends are loose ; the wire is now drawn out of the nose in 
the direction by which it was introduced, one of the divi- 
sions of the ligature emerging with it, the other remaining 
in the surgeon's hand ; to the middle of this portion of the 
cord a piece of lint is attached, to serve as the plug, which 
is drawn into the posterior nares by the first division of the 

Fig. 114. 




328 ON THE METHODS OF ARRESTING' HEMORRHAGE. 

ligature ; the anterior nares are next to be plugged, by in- 
serting lint, and the haemorrhage is thus effectually arrested. 
At the end of two or three days, the plugs may be removed, 
the posterior being drawn out by means of the extremity 
of the cord which has been left hancnncr from the mouth. 
(Fig. 114.) See Liston and Mutter, p. 185. 

A very elegant and useful instrument for plugging the 
posterior nares has been invented by M. Belloc. It is a 
canula of silver, A, curved very much like a catheter, but 
smaller. Through this canal a straight stem of silver, B, 
is introduced, to which is attached a piece of watch-spring, 
C, terminating in a rounded head which has a hole drilled 
in it for the insertion of a ligature. The free extremity of 
the straight rod, B, has a button attached to it, to prevent 
it from being drawn out of the canal ; a ring is soldered to 
the inferior surface of the canula, to aid in holding the in- 
strument. (Fig. 115.) In introducing this, draw the 

Fig. 115. 




watch-spring entirely within the tube so that the head shall 
form a smooth convex extremity to the instrument ; then 
the tube is passed along the floor of the nostril, the curve 
presenting downwards, until its head reaches the extremity 
of the naso-palatine septum, when the watch-spring is 
pushed out, its curved form causing it to find its way 
directly into the mouth ; the head is now drawn forwards, 
and a ligature, with a plug of lint attached, is passed 



ON THE METHODS OF ARRESTING HEMORRHAGE. 329 

through the eye ; the remainder of the operation is managed 
precisely as with the wire above spoken of. 

In hemorrhage from the rectum, if the bleeding vessel 
cannot be tied, or if the blood comes from the venous 
plexus, astringent powders should be introduced ; if these 
fail, a piece of bladder, or a portion of the intestine of some 
animal, filled with pounded ice should be inserted within 
the sphincter ani as high up as may be necessary. But the 
presence of these foreign matters, as well as of the effused 
blood, after a time excites the expulsive efforts of the mus- 
cles and they are discharged. In a case of this kind which 
occurred some years ago at the Pennsylvania Hospital, 
during the attendance of Dr. Thomas Harris, now chief of 
the Naval Bureau of Medicine at Washington, all these 
and other methods of arresting the bleeding failed ; it was 
stopped by pressure upon the bleeding point, effected by 
means of a finger introduced into the rectum and held 
there for many hours, so long as any disposition to recur- 
rence of bleeding was manifested ; — so soon as one indivi- 
dual became fatigued he was relieved by another. 



28* 



CHAPTER IV. 

ON THE DRESSING OF WOUNDS. 

The exposure of the wound for inspection constitutes the 
first step in its treatment. This should be accomplished 
very carefully, after the manner recommended to be pur- 
sued with regard to the examination of fractures. The 
arrest of haemorrhage should next engage attention ; this 
will be effected by some of the means already adverted to. 
It should be borne in mind that, if it be probable that the 
wound may be made to close by direct union of its edges, 
this will be prevented by the application of styptics or 
escharotics to check the bleeding, and therefore if the 
simple pressure produced by the apposition of the edges of 
the wound, and the means used to secure this, be not suffi- 
cient to stop the flow of blood, the ligature should be ap- 
plied to such arteries as bleed. In a simple incised wound, 
all the vessels of sufficient size to require a ligature are 
seen pouring out blood ; but in wounds accompanied by 
severe contusions and lacerations, such as are caused by 
the bursting of fire-arms, or by machinery, it is not at all 
uncommon to see the arteries of the largest calibre project- 
ing an inch or more from the midst of the torn muscles, 
and vibrating with every beat of the heart, yet not emitting a 
drop of blood ; in such cases, ligatures should still be applied 
to these arteries, and at a point where their coats seem to 
be uninjured ; otherwise, after the wound has been dressed, 
and the vitality of the injured parts has become restored 
by warmth and rest, profuse bleeding will occur and render 



DRESSING OF WOUNDS. 331 

it necessary to reopen the wound. It is neither important 
nor advisable to tie very small arteries, as a short exposure 
to the air, and moderate pressure will generally prevent 
these from bleeding, and an unnecessary number of liga- 
tures will interfere very much with the healing of the 
wound. 

All foreign substances, such as dirt, sand and gravel, 
splinters of wood, fragments of clothes, shot, &c, should 
be carefully removed from the wound by the aid of forceps, 
or with the fingers, or by allowing a stream of warm water 
to flow gently over it. Coagulated blood should not be 
permitted to remain upon the injured surface, but should 
be regarded as a foreign body, as much as any of the sub- 
stances enumerated. These preliminary measures having 
been attended to, the proper mode of dressing the wound 
must be determined upon ; and in the selection of the pieces 
of the dressing, it should be borne in mind that lightness 
and cleanliness are of great importance in inducing a rapid 
cure. 

If the wound must heal by granulations, the surgeon 
should not attempt to confine its edges in apposition, as a 
considerable degree of compression must be exercised to 
effect this, causing pain without any adequate good. He 
should be contented with simply placing the limb, or other 
part, in the most favourable position to ensure ease and 
rest, and cover the wound with a suitable dressing, — cold 
water or a poultice, generally, at first, to allay pain and to 
combat inflammation, followed, when these symptoms have 
subsided, by the application of an appropriate cerate, or 
lotion; these dressings should be retained upon the surface 
by strips of adhesive plaster, or by a light bandage. In 
severe contused and lacerated wounds, the best primary 
application is cold water, in the form of irrigation. (See 
Part I.) 



332 DRESSING OF WOUNDS. 

When the wound is of such a character as to afford fair 
reason to expect reparation by the first intention, its sur- 
faces should be placed in apposition along their whole ex- 
tent, from the bottom to the top, and not along its edges 
merely ; otherwise, though the latter may adhere to each 
other, granulations will form beneath the external lips, or 
summit, of the wound, and a collection of matter be the 
result, which will eventually burst through the adhesion 
formed above it, and then the surface will necessarily be 
disfigured by a cicatrix which might have been avoided. 
The proper apposition of the walls of the wound may be 
secured by the use of adhesive plaster, by suture, and by 
suitable bandages, — by one or all of these means. Before 
resorting to any of these, however, the part, particularly if 
the wound be deep, should be placed in such a position as 
shall most, relax the muscles involved: thus, for example, 
if there be an incised wound cutting across the muscles on 
the front of the thigh, the limb should be raised upon an 
inclined plane, and the back elevated in like manner; with- 
out this simple precaution, the sides of the wound can be 
but imperfectly retained in apposition by any compressive 
means. 

1. The mode of applying strips of the common adhesive 
plaster, and of isinglass plaster, has been already described : 
(see Part I :) aided by a proper position of the injured 
part, the strips will be found adequate to secure the adhe- 
sion of most wounds. When the extent of surface upon 
which the strips can be applied is not sufficiently great to 
ensure firm support, their power may be much increased by 
placing a narrow strip of plaster near to, and parallel with, 
each edge of the wound, and crossing the main strips upon 
them. Again, if the strips are subjected to much strain, it 
will be found of importance to make moderate pressure 
upon the muscles by means of a roller, or bandage of Scul- 



DRESSING OF WOUNDS. 333 

tetus. In removing this dressing, the precautions advised 
in the first part of this volume should be attended to. 

From his own experience, the author ventures to think 
that the reports with regard to the irritation caused by the 
ordinary adhesive plaster of good quality, and the liability 
of erysipelas being occasioned by it, are very much ex- 
aggerated. 

Recently it has been ascertained that a solution in ether 
of the " gun-cotton," as commonly prepared, is possessed 
of very strong adhesive properties ; it may be spread upon 
linen or silk, and then applied to the surface ; and it offers 
this advantage over other adhesive matter, viz. : that being 
insoluble in water, the parts surrounding the wound may 
be washed without disturbing the wound itself, by remov- 
ing the plaster which covers it. To separate the plaster 
from the surface, it is necessary to moisten the application 
with ether. 

Gun-cotton is made by saturating carded cotton in a 
mixture of equal parts of strong nitric and sulphuric acids, 
then washing the cotton in water, and drying it at a tem- 
perature of 150°, or less. 

2. Several kinds of suture have been invented for the 
purpose of securing perfect apposition of the surfaces of 
incised wounds. They are passed directly through the 
skin at the edges of the wound, or through strips of adhe- 
sive plaster previously applied near to its margins : to the 
former, the term " wet suture" has been given, the latter is 
called " the dry suture." Of the first there are four varie- 
ties in common use: the interrupted, the continued, the 
quilled, and the twisted suture. 

The interrupted suture is made, by passing a needle 
armed with a single strand of saddlers'-silk, or of some 
other equally strong material, through the skin from with- 
out inwards, entering at the distance of two or three lines 



334 DRESSING OP WOUNDS. 

from the edge of the wound, crossing the latter, and re- 
entering the skin at the opposite margin of the wound,, to 
re-appear a few lines from the edge : the two portions of the 
thread are then tied together in the sailors' knot, as shown 
in fig. 111. The number of sutures thus made varies with 
the length of the w r ound and the strain which must fall 
upon each knot; generally, their number should not be 
greater than may be necessary to retain the lips of the 
wound in close apposition. In order to diminish the num- 
ber of sutures, by supporting each one, strips of adhesive 
plaster may be laid across the wound, between each two 
sutures, leaving space enough between the latter and the 
edges of the plaster, to allow of the escape of fluids from 
beneath. Additional aid is sometimes given to the stitch 
by a roller, or a bandage of Scultetus, passed around the 
wounded part ; but this should be avoided whenever it is 
practicable to do so, as the dressing is thereby rendered 
less light and cool. 

In most cases, the surfaces of the wound will have be- 
come sufficiently adherent, after the lapse of forty-eight 
hours, to admit of the withdrawal of the sutures : this may 

■ . • ,' be effected by passing the 

Fig. 116. . * r . ° 

sharp point oi a pair ot nar- 

row-bladed scissors beneath 
the thread and cutting it, after 
which it mav be srentlv drawn 
out. If allowed to remain 
longer than two or three days 
in the skin, the suture excites 
inflammation and slight ulce- 
ration around itself, thereby 
deforming the appearance of 
the cicatrix. The strips of 
adhesive plaster and, if necessary, the bandage also should 




DRESSING OF WOUNDS. 335 

be retained, in order to give security to the recently formed 
adhesions, after the removal of the suture. The accompa- 
nying drawing illustrates the application of the interrupted 
suture. (Fig. 116.) 

The continued suture is less used than the last. It is the 
one employed in wounds of the intestines, and also in clos- 
ing the incisions made in conducting post-mortem exami- 
nations. It is the stitch commonly used in sewing, and is 
otherwise called the glover's stitch. The needle is first en- 
tered as in making the interrupted suture ; it then crosses 
the wound obliquely from the opposite side to the margin 
first penetrated and is again inserted at a point below the 
first, thus crossing and recrossing the wound obliquely 
until a sufficient number of stitches have been laid, when 
the ends of the thread are secured, at each extremity of the 
wound, by being tied around the first and last stitch re- 
spectively. The distance between the stitches must depend 
upon the length of the wound and the resistance which 
they are expected to overcome ; they may be aided in their 
retentive action by the application of a roller, or a bandage 
of Scultetus. 

The quilled suture is now but little used : Mr. Liston 
says of it, " it is only employed in one operation — that for 
lacerated perinseum. I have used it two or three times in 
cases of this kind." It is effected by entering the needle, 
armed as before, at about four lines from the edge of the 
wound and carrying it downwards to reappear at the bot- 
tom of the wound ; then ascending just exterior to the op- 
posite lip, it emerges at about four lines from the edge, 
opposite the point at which it first entered ; if the wound 
be very deep, it will be more convenient to carry the nee- 
dle from above downwards, on both sides, rather than from 
the bottom of the wound towards the surface. A portion 
of the thread should be left extending from each side of the 



33G 



DRESSING OF WOUNDS. 



Fig, 117. 




incision, and when a sufficient number of stitches have been 
introduced to support the wound, a piece of a gum-elastic 
bougie, or a quill, of the same length as the latter, is placed 

parallel with the in- 
cision on each side, 
3 



between each two 
strands, which are 
then tied upon the 
tube with force suf- 
ficient to retain the 
entire surfaces of the wound in apposition, after they have 
been approximated by the hands. (Fig. 117.) 

The advantages of this suture are, that it forces the sides 
of the wound together throughout its entire depth, instead 
of the edges merely, and that, by the intervention of the 
quills, or pieces of bougie, there is less danger of the skin 
being torn by the threads at the points of puncture. A 
bandage may be employed as an additional support. 

The needle used in these varieties of suture is commonly 
called the surgeon's needle : it is more or less curved, ac- 
cording to the fancy of the operator, and has a double cut- 
ting edge extending about half of its length from the point, 

which should be very 
sharp; the eye should 
be large. The accom- 
panying drawing re- 
presents two forms of 
the surgeon's needle, 
of which the straightest 
will generally be found 
to be the most convenient (fig. 118) : the size should cor- 
respond with the thickness of the thread to be used, and 
the part or character of the wound, for which it is to be 
employed. 



Fig. 118. 




DRESSING OF WOUNDS. 337 

The twisted suture is chiefly used to promote adhesion 
between the edges of incised wounds upon the face, espe- 
cially after the operation for the relief of hare-lip. A well- 
silvered pin, very sharp at the point, is passed with a rota- 
tory motion, through the skin, at a point two or three lines 
distant from the edge of the incision, and brought out on 
the opposite side, at the same distance, the extremities of 
the pin extending beyond the incision ; then the centre of a 
single strand of thread or silk, is thrown over one end of 
the pin, and crossing the wound — of which the lips are 
now in contact, — is turned around the other extremity of 
the pin, in the form of the figure 8 ; thus 
the threads cross and recross until several 
turns are made. Generally two pins are 
introduced, sometimes more, and thread 
twisted upon each, as above. (Fig. 119.) 
When the suture is thus made, the extre- 
mities of the pins are cut off by means of 
a pair of small cutting-pliers. The pins themselves should 
be carefully drawn out at the expiration of two, or at most, 
three days, otherwise ulceration will be excited around 
them, and an unpleasant scar will be the result ; the threads 
should not be disturbed for some days longer. When used 
in an operation upon the upper lip, the invaginated bandage 
shown in fig. 23, will be found a convenient support, if any 
should be needed. 

A particular kind of needle or pin, made of silver, with a 
steel point which may be detached, has been contrived for 
this suture, but the common pin of good quality answers 
just as well, and is much more convenient. 

The dry suture, as before hinted, is made by surrounding 
the part — a limb generally — with a strip of adhesive plas- 
ter placed close to each margin of the wound, and passing 

29 




338 DRESSING OF WOUNDS. 

from one to the other as many stitches of the interrupted 
suture as may be required to retain the edges in apposition. 

M. Baudens, chief surgeon to the " Val de Grace" hos- 
pital, recommends the following kind of dry suture, to ap- 
proximate the edges of the flap after amputation ; he sur- 
rounds the limb, above its cut extremity, with a circular 
bandage, through which he passes pins in front and behind, 
leaving the extremities of the pins projecting ; then, while 
the flaps are brought together accurately by an assistant, 
the surgeon passes from one pin to the opposite, pieces of 
thread, wrapping them around the pins with sufficient 
tightness to retain the flaps in apposition. 

The bandages used to promote union of incised wounds 
are the common roller, the bandage of Scultetus, and the 
invaginated bandage. The first two are employed to give 
support merely to adhesive strips and sutures. The invagi- 
nated bandage acts directly by approximating the edges 
of the incision ; its composition and mode of application 
vary, as the wound is longitudinal or transverse. These 
bandages are applied to the extremities generally. 

The invaginated bandage far longitudinal wounds is thus 
prepared : A linen roller is taken, of a width corresponding 
with the length of the wound, and sufficiently long to make 
several turns around the limb : at the free extremity of this 
roller several slits are made, each about an inch broad and 
six or eight inches long ; and beyond these, at the distance 
of a few inches, fenestras are cut, in number corresponding 
with the slits, (fig. 120.) Thus prepared, the centre of the 
undivided portion of the bandage is placed directly opposite 
the wound, by the margins of which graduated compresses 
(a, a, fig. 121) have been arranged, one on each side: the 
slits, b, b t b, are passed through the corresponding fenestras, 
c, c, c, and these two portions of the roller drawn in oppo- 
site directions until the edges of the wound are in apposition ; 



DRESSING OF WOUNDS. 



339 



Fig. 120. 



Fig. 121. 




(fig. 121.) Then the slits are laid flatly upon the surface, 
and the bandage is completed by circular turns of the roller. 
The efficacy of this uniting bandage is much increased 
by the employment of the compresses, which act very 
much as the quilled suture, by pressing together the entire 
depth of the sides of the wound. It will be found an ad- 
vantageous mode of approximating the surfaces of deep 
incisions of the thighs, particularly. 

T?ie invaginated bandage for transverse wounds. 

Composition. — A piece of linen from two to three feet 
long, corresponding in breadth with the length of the wound, 
and divided at one extremity into two or more slits, each 
about an inch wide and six inches or more in length, to 
correspond with the same number of fenestras made in a 
second piece of linen of the same dimensions as the first; 
two rollers, each six yards long and two and a half inches 
wide; together with two graduated compresses. 

Application. — The limb having been placed in a position 
most favourable for relaxing the divided muscles, the 
surgeon makes a few turns of one roller, b, around the 
limb below the wound, and upon these lays the fenestrated 
bandage, so that the divided portion stretches upon and 
across the incision, while the other part rest? upon the 



340 



DRESSING OF WOUNDS. 




limb below the wound. The extremity of this portion is re- 
flected upwards over 
the turns of the roller, 
which is now resumed 
and made to secure 
the bandage in posi- 
tion. The other band 
is now confined upon 
the limb above the 
wound, in the same 
manner, by means of the second roller, the slits correspond- 
ing in position with the wound : next the compresses, c, c, 
are placed parallel with the edges of the incision, one above 
and the other below : then the slits of one band are passed 
through the fenestras of the other, (fig. 122.) The two 
bands are drawn in opposite directions, so as to approxi- 
mate the lips of the wound, and are firmly fixed by turns 
of the rollers passing respectively above and below the seat 
of the injury. 



CHAPTER V. 

ON THE INTRODUCTION OF THE CATHETER. 

A catheter, in its most general signification, is an open 
tube, made usually of silver, or of gum-elastic prepared in 
a peculiar manner, to which such a form and firmness are 
given as permit of its introduction into the various canals 
of the body. The passages into which such an instrument 
is usually inserted are the eustachian tube, the oesophagus, 
the urethra, and the large intestine. 

1. Catheterism of the eustachian tube. 
The catheter used in this operation is generally of silver, 
about six inches long, slightly curved at the end which 
enters the tube, and gradually increasing in size from this 
to the other extremity. It is open at both ends. 

It will be recollected that the pharyngeal orifice of the 
eustachian tube is, according to Malgaigne, situated at the 
distance of two inches and a few lines from the anterior 
orifice of the nostril of the same side, on a line with the 
external wall of the meatus inferior, and about half way 
between the floor of the nostril and the inferior spongy 
bone. 

To reach this point with the catheter, the following plan, 
recommended by M. Gairal, is probably the best: — The 
patient being seated on a chair, with his head thrown a 
little backwards and supported upon a pillow, the surgeon 
stands in front of him and glides the point of the catheter, 
the instrument having been oiled, along the floor of the 
nostril of the same side, towards the soft palate: the con- 

29* 



342 ON THE INTRODUCTION OF THE CATHETER. 

vexity of the instrument should be directed inwards and 
upwards, its concavity downwards and outw T ards. When 
the point has reached the velum palati, which w r ill be indi- 
cated by a movement of deglutition, the shaft of the catheter 
should be rotated through a quarter of a circle, so as to turn 
the point outwards and upwards to the same extent, and at 
the same time pushed backwards for a few lines, when it 
will have entered the expanded orifice of the tube. (Mal- 
gaigne's Operative Surgery, Brittan's translation, p. 314, 
315— London, 1846.) 

Some surgeons prefer a catheter made of gum-elastic, 
with a stilet, so that, when the point of the catheter has 
reached the orifice of the tube, the stilet may be glided into 
the latter, and the catheter itself slid in upon it. 

Generally, the simple opening of the tube by the entrance 
of the instrument, is sufficient to remove any temporary 
obstruction which may have impeded the free access of 
air to the tympanum. It is sometimes necessary to resort 
to injections of air through the catheter : this should be 
done very gently and cautiously with a small syringe. The 
air introduced may be the ordinary atmosphere, or it may 
be some medicated vapour, according to the supposed con- 
dition of the lining membrane of the tube. 

2. Catheterism of the oesophagus. — The object of this 
operation is, to insert a tube into the stomach, for the pur- 
pose of removing fluids from this organ, or of introducing 
them into it. The catheter used is of gum-elastic, of a 
diameter varying to suit the capacity of different gullets, 
from two feet to two and a half feet long, and furnished 
with a flexible stilet made of a thin strip of whalebone ; the 
extremity which enters the stomach is closed and rounded, 
but fluids reach the interior of the tube, and escape from it, 
through two large eyes placed one on each side, near this 



ON THE INTRODUCTION OF THE CATHETER. 343 

end ; the other extremity is open and is usually somewhat 
expanded, to allow of the easy insertion of a syringe-pipe. 

The following is the simplest and readiest mode of intro- 
ducing the instrument : let the patient be seated, if possible, 
his head thrown back and supported, and his mouth widely 
opened, and kept open, if necessary, by a piece of wood, 
or something similar ; then the surgeon, taking his position 
in front of the patient, guides the stomach-end of the tube, 
previously oiled and having the stilet in its cavity, towards 
the posterior wall of the pharynx ; the stilet should now 
be withdrawn, in order to allow the tube to curve more 
readily as the surgeon pushes it downwards through the 
pharynx and oesophagus. If the patient be possessed of 
his faculties, and his brain be in a condition to respond to 
impressions made upon sentient surfaces, the tube will be 
drawn downwards to the oesophagus by the contraction of 
the pharyngeal muscles, as in swallowing, so soon as the 
point of the instrument comes within the sphere of their 
action ; the surgeon therefore is assisted in the performance 
of the operation, which is thus made much easier. But it 
happens very often that the patient upon whom the opera- 
tion is being performed has stupified himself, so that no 
reflex muscular action takes place. The entrance of the 
tube into the larynx will be recognised by a spasmodic 
cough, or by the rushing of the air through the canal thus 
introduced; the mistake should at once bv rectified. 

Fluids may be thrown into the stomach through the tube, 
by means of a common syringe, or of the stomach-pump 
prepared expressly for this purpose. The first is the most 
simple and is equally effectual. Care should be exercised 
that the liquid injected be of a proper temperature. 

If the object be to remove liquid matters from the 
stomach, a certain amount of fluid should be first intro- 
duced, either simple tepid water, or some other fluid capa- 



344 ON THE INTRODUCTION OF THE CATHETER. 

ble of neutralizing the noxious matter which may have 
been swallowed ; then the whole should be withdrawn by- 
means of the syringe, and the stomach thoroughly cleansed 
by repeated injections of warm water, or mucilage. 

Patients who are unable to swallow, or who obstinately 
refuse to swallow, food, may be sustained by injections of 
nutritious fluids into the stomach through the stomach- 
tube. 

When it is desirable that the tube shall be allowed to re- 
main in the stomach for any length of time, it is recom- 
mended to be introduced by the nostril. For this purpose, 
a tube rather smaller is preferable than if the other method 
be selected ; it is pushed backwards along the floor of the 
nostril, and when it has reached the edge of the velum, the 
stilet is withdrawn, and the flexion of the extremity of the 
tube aided, if necessary, by the finger carried through the 
mouth. This method is not quite so easy as the first. 

3. Catheterism of the upv-ethra. — Very often the urinary- 
bladder, both of the male and female, becomes distended, 
being deprived, from a variety of causes, of its natural ex- 
pulsive power over its contents ; in such circumstances, it 
becomes necessary to resort to some artificial means of 
relief. In many cases, the difficulty may be overcome by 
employing remedies which tend to relax spasmodic muscu- 
lar action, such as a full dose of opium administered by 
the mouth, or in the form of a small enema; — or an enema 
of camphor; or, again, a hot bath may be tried; often, 
too, the operation of a full purgative clyster will be attended 
with evacuation of the bladder. But where these and simi- 
lar means fail, it is requisite to introduce the catheter 
through the urethra into the bladder itself. 

Catheterism of the urethra of the male. — The instru- 
ment used for this operation is a cylindrical tube made of sil- 
ver, or of gum-elastic; it should be about nine inches long and 



ON THE INTRODUCTION OF THE CATHETER. 345 

of a diameter suited to that of the urethra, which of course 
varies in size according to the age of the individual and to 
certain morbid conditions of the canal; the extremity 
which enters the bladder should be conical in shape, closed 
at its point, but perforated just above the latter with two 
or more well- opened eyes ; a moderate degree of curvature 
should also be given to this part of the catheter, though a 
perfectly straight instrument may be passed through a 
healthy urethra ; the other extremity of the tube is open, 
and generally has a small ring attached to each side of it, 
for the purpose of affording means of confining the in- 
strument in the bladder, if occasion require, (fig. 123.) 

Fig. 123. 




The double catheter represented in fig. 1, will be found a 
very convenient instrument. When the gum-elastic cathe- 
ter is used, the proper curve and firmness are given to it, 
by bending the iron-wire inserted in its cavity. 

The following will be found the most convenient method 
of introducing the catheter, in most cases : The patient 
should lie upon his back, or be a little inclined towards the 
right side, his thighs semi-flexed and separated, and his 
back slightly raised in order to relax the muscles which 
would, otherwise, somewhat constrict the canal ; the sur- 
geon places himself on the left side of the patient, and ex- 
poses the head of the penis with the thumb and fore and 
middle fingers of the left hand, at the same time making 
slight compression upon the glans penis so as to open the 
extremity of the urethra; he holds the open end of the 
catheter, previously warmed and oiled, in his right hand, 



346 



ON THE INTRODUCTION OF THE CATHETER. 



between the thumb and the fore and middle fingers, the con- 
cavity of the instrument looking downwards, and engages 
its point in the orifice of the canal, the direction of the tube 
corresponding with the line of flexure of the groin ; (fig. 
124.) With a moderate degree of force, the instrument, 

Fig. 124. 




still in this line of direction, is pressed onwards through the 
canal until its point reaches the membranous portion of the 
urethra beneath the arch of the pubis, when the right hand 
of the surgeon, and with it the catheter, is gradually raised 
and at the same time carried towards the middle line of the 
abdomen, after which it should be thrown downwards more 
and more between the thighs ; its passage through the circle 
of the sphincter muscle at the neck of the bladder will be in- 
dicated, generally, by a slight shiver, or tremor, or a sen- 
sation of nausea, on the part of the patient, and its entrance 



ON THE INTRODUCTION OF THE CATHETER. 347 

into the bladder itself by the escape of urine through it ; 
this should be prevented by the application of the thumb 
upon the open end of the catheter. 

With practice, the instrument may be introduced into 
the bladder, if the urethra be in a healthy condition, without 
touching the penis at all with the hand, after the point of 
the catheter has entered the orifice of the canal ; and this 
will be found to be the least painful method to the patient, 
as well as the one perhaps least liable to obstacles, for the 
instrument will glide along through the urethra without 
being deviated by any forced position of the penis. In 
either method, an instrument of as large a diameter as the 
urethra will admit will be more easily introduced than a 
small one. 

Some of the French surgeons are fond of practising the 
" tour de maitre," as it is called, and this will sometimes 
answer when the more common method has failed. The 
patient may either stand, or lie down, or occupy a sitting 
posture ; the surgeon stations himself on the right side, and 
carries the instrument down the urethra to the arch of the 
pubis, with the concavity looking downwards ; when it 
has reached this point, he gives it a turn of a half-circle, so 
as to bring it parallel with the middle line of the body, the 
concavity looking upwards ; this movement, conjoined with 
a little pressure, generally causes the instrument to enter 
the bladder. 

Even in perfectly healthy urethras, the catheter often 
meets with impediments to its course along the canal, but 
these are readily obviated. Thus the point of the instru- 
ment may come in contact with the front of the pubis, 
owing generally to slight deviation of the position of the 
penis, or to too great pressure against the superior surface 
of the urethra from the point of the catheter. Again, when 
the tube has come within the action of the muscles which 
compress the membranous portion of the canal, and, still 



348 ON THE INTRODUCTION OF THE CATHETER. 

more, when it has reached the neck of the bladder, its far- 
ther advance will be often checked by the contraction of 
the muscular fibres at these points ; but a little patience on 
the part of the surgeon is all that is required to overcome 
this momentarv obstacle. 

When the cause of the obstruction is an organic altera- 
tion of the urethra, or of the parts connected with it, much 
more difficulty is experienced in the introduction of the 
catheter. The most common sources of embarrassment of 
this kind are, stricture and enlargement of the prostate gland. 

If there be a stricture of the urethra, the size of the 
catheter must be adapted to the diminished calibre of the 
canal ; it is necessary therefore to have a number of cathe- 
ters of different sizes always at one's command. The re- 
sort to much force in introducing the instrument should be 
avoided, particularly when the stricture is within the pubic 
portion of the canal, as a false passage may be made more 
easily at this portion than in advance of it. The operation 
may be assisted by drawing the urethra over the catheter; 
by first using a large instrument, until the stricture is 
reached, and then drawing the penis over it, so as to make 
an entrance fully into the strictured part, then taking a 
smaller instrument with a resort to the same manipulation. 
The use of the warm-bath, the application of warm fomen- 
tations to the perinseum, or the administration of anodyne 
medicines, will usually assist the operation, by relaxing the 
muscles which directly or indirectly constrict the urethra. 

M. Amussat frequently resorts to forced injections of the 
urethra, to relieve retention caused by stricture. He in- 
troduces a catheter of gum-elastic, open at both ends, as 
far as the stricture, and then by means of a syringe forces 
a stream of warm water along the urethra ; this removes 
any mucus which may have collected, and dilates the canal 
somewhat, so that the patient can generally pass a small 
quantity of urine. 



ON THE INTRODUCTION OF THE CATHETER. 



349 



One of the most common causes of difficulty in the in- 
troduction of the catheter, particularly in old men, is an 
abnormal development of the prostate gland. The middle 
lobe becomes enlarged, sometimes to a very great degree, 
and encroaches, proportionally to its size, upon the canal 
at the neck of the bladder, thereby opposing a mechanical 
obstacle to the ingress of the instrument. (Fig. 125.) There 

Fig. 125. 




are several expedients by which this difficulty may gene- 
rally be remedied. If the gland be not very large, a silver 
catheter may usually be passed, by pressing the external 
•end of the instrument well downwards, when the point has 
reached the prostate ; or a gum-elastic catheter may be in- 
troduced by withdrawing the stilet a little, when the pros- 
tatic part of the urethra has been attained, and pushing the 
tube onwards with moderate force and cautiously ; the 
point of the instrument, meeting with the obstacle, will yield 
to it in virtue of the flexibility of the gum, and will be 
thrown upwards so as to clear the obstruction. If these 
methods fail, the surgeon should insert the forefinger of his 
left hand, previously oiled, into the rectum, and press the 
point of the catheter upwards towards the pubis : if the 

30 



350 OS THE INTRODUCTION OF THE CATHETER. 

gland is very large, the patient should assume the erect 
position, or he may bend his body forwards, supporting his 
hands against the back of a chair or a table, so that the 
mere weight of the prostate will open the neck of the blad- 
der to the passage of the instrument. In cases of obstruc- 
tion from this cause, the curve of the catheter should be 
somewhat increased, especially near its point, so that it 
will pass over, and in advance of, the enlarged gland, in- 
stead of impinging directly against it, as would probably 
be the case were the degree of curvature smaller. 

Where much difficulty is experienced in introducing the 
catheter, or in the process of dilating a stricture, it is often 
advisable to allow the instrument to remain in the bladder. 
A silver catheter is borne with rather less comfort than a 
gum-elastic, but the latter soon becomes corroded and 
roughened by the action of the urine upon it : hence if the 
gum catheter is used, it should be removed at least once in 
every twenty-four hours, and a new one substituted for it 

A very simple mode of securing the catheter in the blad- 
der is the following : pass a ring made of ivory or of metal, 
covered with linen, or of a cylinder of linen stuffed with 
: ; .ton, over the penis, and secure it against the pubis by 
.. means of four tapes passing around the 

— ~ ^ pelvis and between the thighs, on each 

I jff_ gi^v^ side; attach the catheter to this ring 
-^2^1--^ K- ky tapes connected with the rings of 
the instrument, or tied around its extre- 
mity, if it be a gum-elastic tube. 

M. Velpeau advises that a piece of 
linen be passed around the penis, just 
behind the corona glandis, and that four 
tapes, secured to the rings of the instru- 
ment, or tied around the extremity, be 
twined about it. (Fig. 126.) The first 




ON THE INTRODUCTION OF THE CATHETER. 351 

plan will be less likely to cause injury to the penis, in case 
of erection of the organ. 

Catheterism of the female urethra is attended with fewer 
difficulties than that of the male, owing chiefly to the dif- 
ference in the conformation of the two canals. 

The instrument employed in the operation is made of sil- 
ver, generally; its form and dimensions may be very well 
seen by a reference to fig. 1, A and B, and to the text ex- 
planatory of it. But a gum-elastic catheter, even without 
a stilet, may easily be introduced. The only difficulty in 
the performance of the operation, in most instances, con- 
sists in inserting the point of the catheter into the orifice of 
the urethra, without exposing the parts ; but a very little 
practice upon the subject will enable the surgeon to acquire 
sufficient skill to operate satisfactorily on the living female. 

The simplest rule which can be given for ascertaining 
the position of the orifice of the urethra in the female is 
this : (the patient being on her back,) introduce the tip of 
the forefinger of the right hand within the labia and the 
orifice of the vagina, and press its palmar surface against 
the summit of the arch of the pubis, at the same time push- 
ing the point of the finger a little forwards ; it will now 
readily and immediately feel itself entering the mouth of 
the canal, which is forced a little open to admit its tip. 

The catheter may be thus introduced : place the point of 
the forefinger of the right hand at the orifice of the urethra, 
as just directed, and with the left hand enter the catheter, 
using the finger of the right hand as a guide ; or only one 
hand need be employed, thus: lay the catheter upon the 
palm of the right hand, the point of the instrument resting 
on the top of the forefinger, the other extremity on the ball 
of the thumb, and supported in this position by the thumb 
and middle-finger, both somewhat flexed ; now place the 
tip of the forefinger at the orifice of the urethra, in the 



352 ON THE INTRODUCTION OF THE CATHETER. 

manner already directed, and with the thumb and middle- 
finger cause the catheter to glide along upon the forefinger 
and enter the canal. 

When the uterus is higher up in the pelvis than usual, 
from any cause, the orifice of the urethra is usually drawn 
behind the arch of the pubis ; in such cases, the point of 
the finger must be introduced a little farther than is other- 
wise necessary, in ascertaining the position of the meatus, 
and rather behind the pubis ; but the operation is scarcely 
rendered more difficult on this account. 

It sometimes happens that the urethra is much com- 
pressed against the pubis by a tumour in the pelvis, as a 
child's head during labour: in such circumstances, if it is 
necessary to remove the urine from the bladder, a gum- 
elastic catheter of small size should be used, or, which 
is perhaps better, a flattened silver catheter; such an in- 
strument can be had at the shops of surgical instrument 
makers. 

Should it be deemed advisable to allow the catheter to 
remain for any length of time in the bladder, it may be 
easily secured by applying a double- T bandage around 
the pelvis, and attaching the rings of the instrument to 
the strips which pass between the thighs and over the 
perineeum. 

4. Catheterism of the large intestine is sometimes re- 
sorted to, for the purpose of removing the gases which ac- 
cumulate so largely in some diseases. Thus, in peritonitis, 
the bowels often become so much distended with flatus, as 
to aggravate the patient's suffering in a high degree. In 
such cases, relief is occasionally obtained from the intro- 
duction of the common stomach-tube. The mode of per- 
forming the operation is simple in the extreme; and yet, 
from the tortuous course of the intestinal canal, it is often 
exceedingly difficult to pass the tube to any considerable 



ON THE INTRODUCTION OF THE CATHETER. 353 

distance above the rectum. The most successful plan is, 
to select a large tube, having within it a stilet of whalebone 
sufficiently thick to impart to the tube a certain degree of 
firmness, yet so flexible as to accommodate itself to the 
winding course of the canal ; the tube should be oiled, and 
introduced with a rotatory motion and slowly: the point 
of the catheter may often be felt passing along the sigmoid 
flexure of the colon, by the hand placed on the parietes of 
the abdomen. 

5. Catheterism of the larynx and trachea is rarely prac- 
tised ; but in some cases of oedema of the glottis and simi- 
lar obstructions, it may perhaps be advisable to pass a tube 
into the air-passages from the mouth. The operation is not 
at all difficult: the patient being seated, or recumbent, the 
head should be thrown back, the mouth widely opened, and 
the base of the tongue depressed by means of a spoon ; then 
the surgeon, taking a silver tube curved like the ordinary 
catheter for the urethra, but rather larger and open at both 
ends, or a stomach tube curved by means of a stilet, passes 
it through the mouth directly into the larynx, the patient 
being directed to prolong his inspiratory act : a momentary 
cough may be excited by the entrance of the tube into the 
larynx, but this soon subsides, so that the instrument may 
be permitted to remain, having been secured by attaching 
its external end to some conveniently-placed bandage, as 
around the neck, for example. 



30* 



CHAPTER VI. 

ON THE ADMINISTRATION OF INJECTIONS. 

The term injections, or enemata, is applied to liquids 
introduced into the canals or cavities of the body by means 
of syringes contrived for the purpose. 

The matter of the injection consists of water, holding in 
solution, or suspension, certain medicinal substances, in- 
tended to produce some special effect, — or of water alone. 

The syringes used in the administration of enemata vary 
in form and size, according to the amount of fluid to be 
injected, and the canal into which it is to be introduced. 
The rectum, the vagina, the urethra, and the lachrymal 
duct are the passages which are most frequently acted upon 
in this manner. 

1. Injections by the rectum. 

The syringes for the rectum are made of different sizes, 
to contain from two fluid ounces to a pint, or more. In 
selecting them, those instruments should be chosen of which 
the beaks are large and well-rounded at the extremity, so 
that there shall be less probability of inflicting any injury 
upon the mucous membrane of the rectum during their intro- 
duction. 

Before using the syringe, the beak should be warmed 
and anointed with oil, or lard; and when it is being intro- 
duced into the rectum, great gentleness and caution should 
be observed, otherwise, as has happened at times, the in- 
testine may be torn, or even perforated, particularly when 



ON THE ADMINISTRATION OF INJECTIONS. 355 

its coats are not in a perfectly healthy condition. Its 
entrance into the anus may be facilitated by first passing 
in the forefinger of the left hand, well oiled, and then sliding 
in the beak upon it. While the piston is being forced down 
with the right hand, the head of the syringe should be 
firmly held by the fingers of the left, so that the instrument 
shall not be pushed further into the bowel. The fluid 
should be forced from the tube gradually; and after all 
has been ejected, the beak of the instrument should be re- 
tained a few moments in the rectum, lest, during its re- 
moval, the injection pass out with it. 

The above remarks are of general applicability : there 
are some modifications of the process, however, which 
should be borne in mind. Thus, it is frequently advisable 
that a large quantity of fluid shall be thrown into the bowel, 
a larger quantity than can be contained in the syringe 
usually employed. In such cases, the instrument must be 
carefully and slowly withdrawn from the anus, refilled, and 
again introduced and emptied, until the requisite amount 
shall have been injected ; or, the self-injecting syringe may 
be more conveniently used — an instrument made like the 
common forcing pump, having connected with it one tube, 
through which the fluid enters the syringe from the vessel 
which contains it, and a second, which is inserted into the 
rectum, and through which the injection finds its way into 
the bowel. With this very convenient apparatus, any 
quantity of fluid may be thrown into the large intestine, 
until it is filled, either by the patient's self or by an attendant. 
Again, it sometimes happens that an obstruction of the 
lower part of the bowel prevents the introduction of the 
matter of the injection beyond a certain point, if the ordi- 
nary method be adopted. In such cases, it is customary 
to pass a stomach tube, in the manner recommended in the 
last chapter, as far into the canal as may be practicable, 



356 ON THE ADMINISTRATION OF INJECTIONS. 

and to inject the fluid through it. This method will be 
found effectual, oftentimes, in overcoming the constipation 
which attends some cases of colic. 

The composition of the enema must be adapted to answer 
the particular indication for which it is given. When it is 
employed merely to distend the bowel by its quantity, 
simple warm water, or warm mucilage, may be used. The 
ordinary purgative injection consists of a tablespoonful of 
common salt and the same bulk of molasses, dissolved in a 
pint of warm water, to which a small piece of soap may 
be added with advantage. The anodyne enema consists 
merely of half an ounce or an ounce of mucilage, holding 
in suspension or solution the anodyne element, — as, for 
example, thirty-five or forty drops of laudanum. This small 
quantity of fluid is preferred, as being less likely to induce 
contraction of the expulsive muscles by its mere presence, 
than if a larger amount were introduced; and this fact 
should be recollected in giving any injection which is in- 
tended to be retained in the rectum, to produce some general 
impression upon the economy. 

" Suppositories" are sometimes used as substitutes for 
enemata: they may be so formed as either to induce an 
evacuation of the lower bowel, from the irritation of their 
presence in the rectum, — or, in consequence of the absorp- 
tion of the medicated materials of which they are composed, 
they may be retained for a considerable length of time in 
the gut, and produce the peculiar effect cf the medicine 
upon the system. 

The suppository intended to produce catharsis is ordina- 
rily made of a piece of castile soap cut to correspond with 
the form and size of the rectum ; it should be oiled, and 
then inserted gently within the sphincter muscle. 

Any medicine may be administered in the form of a 
suppository, by combining it, in the state of powder, with 



ON THE ADMINISTRATION OF INJECTIONS. 357 

liquorice, or some other soft adhesive substance ; then, hav- 
ing reduced the mass to the proper dimensions and figure, 
let it be oiled and introduced into the lower extremity of 
the rectum. As a general rule, the quantity of the medi- 
cine used in the suppository may be three or four times 
greater than the proportion of the same medicine, when 
given by the mouth. 

It should be borne in mind that a very frequent resort to 
the employment of suppositories, or to the administration 
of injections, produces irritation of the mucous membrane 
lining the lower part of the rectum, and is apparently an 
exciting cause of the development of haemorrhoids and 
other organic alterations of this portion of the intestinal 
canal. 

2. Injections by the vagina. 

The vagina] syringe is usually about four inches long 
and an inch in diameter, terminating in a rounded head 
which is pierced with a number of holes, like a sieve. 

No especial directions are required to enable one to in- 
troduce this instrument, farther than that it should be oiled 
before so doing. 

The cavity of the uterus itself may be washed, by pass- 
ing a gum-elastic catheter through the os uteri, and inject- 
ing the interior of the organ with tepid water or mucilage, 
by means of an ordinary syringe, of which the beak is in- 
serted into the open extremity of the catheter. 

3. Injections by the urethra. 

A small glass syringe capable of containing about half 
an ounce, and having a beak well rounded at the tip, is the 
best instrument for injecting the urethra. The piston should 
terminate, at its free extremity, in a ring large enough to 
receive the thumb, so that the fluid may be forced from the 
syringe and the syringe itself held by the right hand, while 
the left supports the penis. The beak of the instrument 



358 ON THE ADMINISTRATION OF INJECTIONS. 

should be oiled and inserted very carefully into the orifice 
of the urethra, lest the lining membrane be injured. 

It is generally recommended that pressure be made upon 
the perinseum opposite the neck of the bladder, in order to 
prevent the fluid of the injection from entering the cavity 
of this organ ; but this precaution is scarcely necessary, if 
the piston of the syringe is forced down with a proper de- 
gree only of rapidity, and if only sufficient fluid be expelled 
to fill the canal, — the sphincter muscle preventing the fluid 
from reaching the bladder itself. 

The interior of the bladder may be acted upon by fluid 
injected through the urethra, a catheter having been first 
introduced, and the beak of an ordinary syringe then in- 
serted into the mouth of the tube. Care should be taken, 
that the fluid thus introduced into the bladder has been 
freed from all solid matter which, if retained, would serve 
as the nucleus for calculous formations ; it should, more- 
over, be tepid in temperature, and of a slightly mucilagi- 
nous character. 

In injecting the urethra of the female, a catheter should 
first be inserted within the orifice of the canal, the beak of 
the syringe adapted to it, and then the fluid forced through 
the tube into the urethra. 

4. Injection by the lachrymal duct. 

The instrument by means of which this is accomplished, 
is known by the name of " Anell's syringe;" it is a small 
syringe having a number of very fine tubes appertaining to 
it, one of which, when the duct is to be injected, is attached 
to the beak of the syringe and then inserted into the infe- 
rior puncture lachrymal. The method of using the instru- 
ment is thus described by Malgaigne : " Seat the patient 
opposite the light. If you operate on the left eye, stand 
before him, and with the thumb or fingers of your left hand 
draw the lower lid outwards and a little downwards, so as 



OF DIMINISHING PAIN DURING OPERATIONS. 359 

to direct the lachrymal puncture forwards and outwards. 
Then, having filled the syringe and applied one of the small 
tubes to the beak, hold the instrument as a pen in your 
right hand, which you rest on the cheek, and carefully in- 
sert the end of the tube in the puncture; first, obliquely 
downwards and inwards, then, after having entered one 
line, directly inwards. At the distance of three and a half 
lines you may stop, but it is advisable to penetrate as far 
as four and a half lines, in order to reach the sac ; then 
inject slowly, at first." On the right eye the operation 
may be performed also with the right hand, by standing 
behind the patient, and resting the hand upon the external 
orbital process of the frontal bone. If the duct is pervious, 
the fluid thus injected will pass through it and appear ex- 
ternally by the nostril ; and if it be not pervious at first, the 
obstruction may oftentimes be removed by repeated use of 
the syringe. The first injection should consist of tepid 
water or mucilage; subsequently, the fluid may be ren- 
dered somewhat astringent, or be otherwise medicated. If 
the injection cannot be passed through the duct, a fine silver 
probe, of which the point is round and smooth, may be in- 
troduced as directed for the syringe. 



OF THE MEANS OF DIMINISHING PAIN DURING OPERATIONS. 

Pain is at all times an inconvenience, and often a posi- 
tive evil both to the surgeon and to the patient who is un- 
dergoing an operation, since it interferes with the quiescence 
which is essential to the performance of some operations 
and of importance in all; and, moreover, if it be very vio- 
lent and protracted, it may produce such an impression 
upon the patient, as shall impair the success of the opera- 
tion, during its performance and subsequently. Hence the 



360 OF DIMINISHING PAIN DURING OPERATIONS. 

very general custom of administering to patients who are 
about to submit to surgical operations " some sweet, obli- 
vious antidote," for the purpose of calming their apprehen- 
sions of suffering and danger, and to obtund, in a measure, 
their sensibility to pain, so that the operation may be per- 
formed with less discomfort to themselves and with more 
facility to the surgeon, than might otherwise be possible. 

With this view, it has been usual to give a dose of one 
of the preparations of opium, a short time previous to the 
operation, so that, when this is being performed, the patient 
may be under the influence of the anodyne, not to such a 
degree as shall completely stupify him, but so far as to be 
calmed and tranquillized by it. The precise amount of 
opium necessary to induce this condition, cannot be deter- 
mined accurately and for all cases, since different indivi- 
duals are susceptible of pain and of the influence of nar- 
cotics in very different degrees. In ordinary cases, from 
forty to fifty drops of laudanum may be administered to an 
adult, fifteen or twenty minutes before the commencement 
of the operation, and this interval should be passed as 
quietly as possible. 

It has long been known that nitrous oxide gas and the 
vapours of many vegetable narcotics produce, when inhaled, 
a degree of insensibility to physical suffering, and opera- 
tions have been performed upon persons thus affected ; simi- 
lar results have been attained by the influence of animal 
magnetism. But the importance of these agents is slight, as 
compared with that of more recent discoveries, — the influ- 
ence of inhalations of the vapour of sulphuric ether and of 
chloroform. 

The applicability of the vapour of sulphuric ether to the 
purpose now under consideration, was first established by 
Dr. W. T. G. Morton, of Boston, on the 30th September, 
1846. (See Report of the Mass. Gen. Hospital, Jan. 26th, 



TO DIMINISH PAIN DURING OPERATIONS. 361 

1848 — noticed in Am. Journ. of Med. Sc, April, 1848.) 
The influence of chloroform in producing similar effects, 
was first determined by Professor Simpson, of Edinburgh. 
(See Am. Journal of Pharmacy, Jan. 1848.) 

Since their effects became generally known, these agents 
have been employed to relieve pain in all sorts of opera- 
tions, and in very many diseases ; they have been adminis- 
tered, too, by the ignorant as well as by the learned, and 
without any discrimination of cases. It is not at all sur- 
prising, therefore, that in many instances injurious, and 
sometimes fatal, consequences have ensued. It would be 
out of place to discuss fully, in this volume, all the circum- 
stances connected with the use of these agents. Indeed, 
sufficient materials for a full investigation of their mode of 
action have not yet been made public. From the few post- 
mortem examinations w T hich have been had of persons 
who have died apparently in consequence of the inhalation 
of these vapours, it would seem that they produce death 
by asphyxia, — the lungs, the heart, the brain, having been 
found, in these cases, to be much congested, and the blood 
dark-coloured and more fluid than usual. The legitimate 
inference from these facts is, that these vapours should not 
be resorted to in persons suffering from congestion of these 
organs, or in whom any important disease of these organs 
exists. And although it may be admitted that a sufficient 
amount of testimony has been accumulated to show that 
the inhalation of these substances is not, under proper regu- 
lations and in well-discriminated cases, attended with ma- 
terial danger, and that it is even a valuable aid to the sur- 
geon in many operations, it must also be acknowledged, on 
the other hand, that we have facts sufficient to prove that, 
without these precautions, and where the amount of pain 
to be experienced is not very great, these agents should not 
be used. It should be recollected, that the mere perform- 

31 



362 TO DIMINISH PAIN DURING OPERATIONS. 

a nee of an operation, with comparative freedom from suf- 
fering to the patient and with satisfaction to the surgeon, 
is but one step towards the cure of the affection for which 
the operation is performed : the treatment of the patient 
subsequently is a matter of equal importance ; and with 
reference to this part of the surgeon's duty, any cause 
which disturbs the healthy play of important functions, 
whether it be the impression of too intense pain, or of too 
powerful narcotic agents, is to be regarded as an evil. 

The vapour of chloroform is probably less safe than that 
of sulphuric ether, although it acts more promptly and in 
smaller quantity, — six or eight inspirations being sometimes 
sufficient. No precise rule can be laid down as to the 
quantity of the fluid, or the period of inhalation, necessary 
in either case to produce insensibility to pain, children and 
persons debilitated by disease, or other causes, being 
affected much more speedily than those in opposite circum- 
stances. The vapour should be inhaled until the patient 
becomes insensible to pain, unless some unpleasant effect be 
produced before this condition is attained ; and this insensi- 
bility should be prolonged, as may be necessary, by re- 
application of the apparatus to the mouth, from time to 
time, as the influence of previous inhalations passes off. 

Many varieties of inhalers have been contrived for the 
administration of these vapours, some of them complicated 
and expensive ; the object of all, however, is the same, — to 
allow atmospheric air to enter the lungs, loaded with the 
vapour of ether, or of chloroform. This end may be se- 
cured by using either of the inhalers illustrated by the 
accompanying wood-cuts, as perfectly as by the more 
complex apparatus. (Figs. 127 and 128.) Figure 127 
represents a double-necked bottle into which the liquid is 
introduced ; through one neck of the bottle, a glass tube 



TO DIMINISH PAIN DURING OPERATIONS. 



.163 



Fig. 127. 



Fig. 128. 




(r=^ 





passes, reaching below the level of the liquid ; into the 
other a bent tube is inserted, through which the patient 
breathes. The tubes must be tightly fixed in the necks of 
the bottle, and the inspirations of the patient must be made 
through the bent tube, his lips firmly compressing the glass, 
the air expired from the lungs passingoutthrough the nostrils. 
Figure 128 shows a common wide-mouthed bottle, having 
tightly fixed in the orifice a cork through which the tubes 
enter the bottle as in the other case. But it is not neces- 
sary to use any apparatus, — a sponge, or a piece of linen, 
wet with the liquid and applied to the mouth, being fully 
as efficacious. The purest preparations only of ether and 
chloroform should be employed. Before commencing the 
inhalation of the vapour, the patient should be placed in 
the position most convenient for the performance of the 
operation, whatever it may be. 

If any individual to whom these agents have been ad- 
ministered should not revive spontaneously, stimulating 
applications should be made to the surface, among the best 
of which is boiling water ; this should be placed in a cup 
covered with a towel, and then the cup inverted upon the 



3G4 TO DIMINISH PAIN DUFFING OPERATIONS. 

chest. (Am. Journ. Med. Sc. p. 556, April, 1848.) Arti- 
ficial inspiration should be resorted to, if other means fail. 
The reader will find details as to the mode of preparing 
ether and chloroform in the Am. Journ. of Pharmacy, for 
Oct. 1847, and Jan. and April, 1848. Numerous articles 
relating to their employment are contained in the Am. 
Journ. of Med. Sc. for 1847-8, to which reference should 
be made by those who may be disposed to test the action 
of these agents. Besides these publications, the author 
would recommend attention to the report of Dr. Isaac 
Parrish, of this city, to the College of Physicians, published 
in the " Transactions" of that body. 



APPENDIX OF FORMULA. 

The following list of formulas will be found to contain 
many which have been proved to be valuable, in answering 
the indications for which they are directed. 



LOTIONS. 

I. ASTRINGENT LOTIONS. 

1. Wash for secondary venereal ulcers, particularly of the 
throat — 

R. Cupri sulphatis Bij, 
Pulv. cinchonoe 3ss, 
Aquse fluvialis fgviij. 
M. ft. lot.— Dr. Physick. 

2. R. Tinct. myrrhse f 3j — f3ss, 

Aquse fluvial, f 3viij. 
M. ft. lot. 

3. R. Creasotse gtts. xx — gtts. 1, 

Aquse fluvial. fSyj. 
M. ft. lot. 

4. R. Tannin Bj, 

Spt. vini gallici. f gss, 
Mist. Camphora3 f 3vss. 
M. ft. lot, — For salivation, spongy gums, &c. 

31* 



366 APPENDIX. 

5. R. Sodii chlorid. (sol.) 

Tinct. myrrhse, aa fjss, 
Aquse fluvial, fgiv. 
M. ft. lot. — Uses the same as the last. 



II. STIMULATING LOTIONS. 



6. R. Acidi nitrici f 3j — f 3ij, 

Aquse fluvial., f gviij. 
Aqua? rosse, f 3j. 
M. ft. lot. 

7. R. Ammonia? muriat., 3j — 3ij, 

Aquae fluvial., f 3viij, 
Tinct. opii, f 3j. 
M. ft. lot. — For painful indolent ulcers. 

8. R. Acid, cyanhydrici, f 3j, 

Mucilag. acacice, f^viij. 
M. ft. lot. — To relieve the itching in prurigo. 

9. R. Hydrarg. chlorid. mit., 3ij, 

Liquoris calcis, 3viij. 
M. ft. lot.—" The black wash." 

10. R. Hydrarg. bi-chlorid., grs. x — 9j, 

Liquoris calcis, gviij. 
M. ft. lot. 

11. R. Spt. vini rectificati, 

Tinct. camphorre, aa f 3iijss, 
Liquor, plumbi, f3j. 

M. ft. lot. — To be rubbed upon the part several times daily, 
occasionally suspending it. For indolent fibrous tumours of the 
breast. — Brodie. 



APPENDIX. 367 

12. R. Iodini, 9j, 

Potassii iodid., 3ss", 
Aquas fluvial., f 3viij. 
M. ft. lot. — For application to scrofulous and other indolent 
tumours. 



III. EVAPORATING AND REFRIGERANT LOTIONS. 

13. R. Ammonias mur., 3j, 

Potassas nitrat., 3ij, 
Vinegar, fgj, 
Aquas fluvial., f Sx. 
M. ft. lot. — Schmucker's frigorific mixture. 

14. R. iEtheris sulphuric. 

Alcohol, 

Aquas plumbi, aa fgj. 
M. ft. lot. 

15. R. Sodii chloridi, 

Potassas nitratis, 
Ammonias muriat. aa 3ij, 
Aquas fluvial., q. s. ad mist, solvend. 
M. ft. lot.— Druitt. 

16. R. Spt. vini rectif., f 3j, 

Aquas fluvial., fgvij. 
M. ft. lot. 



CERATES 



17. R. Resinas, 3j. 
Cer. flav. 3ij, 
Adipis, 3v. 
M. ft. cerat. — For burns. — Physick. 



368 APPENDIX. 

18. R. Cerat. plumbi, s'acet. 

Cerat. simplicis, aa gss, 
Hydrarg. chlor. mit. 
Pulv. opii, aa 3j. 
M. ft. cerat. — For burns, painful ulcers, &c. 

19. R. Unguent, hydrarg. nit., 3j, 

Cerat. simplicis, 3iij — 3ss, 
M. ft. cerat. — For sore nipples, &c. 

20. R. Pulv. camphorse, Bj — 3j, 

Cerat. simpl., 3j. 
M. ft. cerat. — A stimulating salve. 

21. R. Hydrarg. chlorid. mit., grs. vj, 

Pulv. opii, grs. x, 
Cerat. simpl., 3ij. 
M. ft. cerat. — For indurated chancres. 

22. R. Acid, hydrocyanic, gtts. xx, 

Cerat. simpl., 3ij. 
M. ft. cerat. — For papular eruptions attended with itching. 

23. tJL. Creosotse, gtts. xx, 

Cerat. simpl., 3ij, 
Zinci oxid., 3j. 
M. ft. cerat. — For scaly eruptions. 

OINTMENTS. 

24. R. Potassse carb. gss, 

Aquas rosse f3j, 
Hydrarg. sulph. rubr. 3j 9 
01. bergam. f gss, 
Fl. sulphuris, 
Adipis aa gix. 
M. ft. unguent. — Bateman's aromatic sulphur ointment, for 
itch, &c. 



APPENDIX. 369 

25. R. Picis liquid, fgj, 

Salt butter, 3ij. 
Melt together, and add of 
Common potashes, 3j 5 
Grafe's itch ointment. 

26. R. Unguent, hydrarg. fort. 3j, 

Antimon. et potass, tart. 3j, 
Iodini, grs. x — xv. 
M. ft. unguent. — To be rubbed upon the part daily, until it 
pustulates. For chronic glandular tumours, old indurated buboes, 
&c. — H. Johnson. 

27. R. Morphia? acetat. grs. vj. 

Pulv. gallse, 3j. 
Unguent, stramonii, 3j. 
M. ft. unguent. — For hemorrhoids. — Harlan. 

28. rjL Sodse bi-carb. 3j, 

Adipis, 3j, 
Pulv. opii, 9j. 
M. ft. unguent. — For lichen, prurigo, &c. 



LINIMENTS. 

29. R. 01. tiglii. f 3ss, 

01. cinnamomi, f 3j, 
01. olivse, f 3j 5 
Lin. cantharid, f 3ij. 
M. ft. liniment. — For neuralgia. — Prof. Jackson. 

30. R. 01. olivae, 

Alcohol aa fjj, 
Tr. camphorse, f3ss, 
Aquse ammonise, f 3j. 
M. ft. liniment. — For indurated breasts. 



370 APPEXDIX. 

31. Ft. Ol. terebinth, 
01. lini aa Oss, 

Ol. succiiii, 

OL juniperi aa f gh \ 

Petrol. Baxbadensis, gig, 
Petrol. American. 3j. 
M. — "The British Oil." Tc : used diluted with olive oil, 
or lard, as a stimulating liniment, or ointment. 



INDEX 



ABDOMfeN, bandage for, ... 






104 


Acids, counter-irritation by, 


. 




300 


cauterization by, ... 


- 


. 


313 


Actual cautery, - 


. 




312 


Acupuncture, .... 


. 


. 


305 


Adhesive plasters, ... 


. 




36 


iEther, ..... 


. 


. 


360 


Amesbury, .... 


. 


- 192 


,217 


Air-passages, catheterism of, - 


- 


. 


353 


Ammonia, as a counter-irritant, - 


. 




299 


Anchylosis, relief of partial, 


. 


. 


259 


Aneurism-needles, - 


. 




325 


Apparatus for treatment of fractures, - 


_ 


m 


123 


dislocations, - 


. 




235 


the immovable, of DiefFenbach, 


. 


_ 


132 


Langier, 


. 




131 


Larrey, - 


. 


. 


128 


Seutin, 


• 




129 


Velpeau, 


- 


. 


130 


of dressings - 


. 




29 


of instruments, 


_ . 


m 


26 


Arteries, cauterization of, - 


. 




31.1 


compression of, 


- 


. 


314 


ligature of, - 


. 




321 


plugging of, 


- 


. 


320 


torsion of, - 


- 




321 


Arteriotomy, ----- 


. 


. 


280 


Artery, wound of, in bleeding, 


. 


. 


278 



Bandages, and their application, 



70 



372 



[JXDEX. 



3-. .:-_■;. :v: 5. /.i.e. :: t'.ie ::ie:. .... 71 

"iiitg if tie. ...... 71 

1: .::::- tftie. ..... 

:_t : it tier. ...... 73 

tie unite;? tir. ..... 

t.ie :::5set. - - - . . - 75 

tie ClT;;;-r. . 

tie extr-eiiir, - - - - - - 77 

the invaginated, - . . . . % : 

lie irtttei. ---..„" 

the laced, 

t.ie re: irrent. - - - . . . --' 
tie retailing. ..... 

tie =-::i. - - . . . 7.5 

tie siiii ...... 73 

the spiral reversed, . - - . - 74 

the split, or tailed, ..... 79 

:_t sie-r.i. ------ 81 

tie strsj-e-strr. ..... gl 

Einiires. :t~i<tind, ...... 75 

Biriigirg. Mivor's sjstem :•:. - - . . . 82 

B-irtin's iiniige fir \z~ er ;e~ , ..... 14^ 

bran-dressing. ...... 230 

iitrire :f tie riiiis. ..... 175 

Ei-ntti's "ei: merit ::"i:er=. ..... 33 

Eiming. ........ 61 

Banden's dry suture, - - . . . 555 
Bell's inclined plane, - - . . . . -18 

BeDoc's instrument for epistaxLs. . - . . . ,;,- 

Bieimr. :ieri:::rm ::: geneni - 262 

for topical, - - - . . agg 

from flie ankle, - - - . _ -273 

trim tie irm, ...... ; ; 

from the external jugular. - - . . -274 

trim tie iini - . . . . 272 

from the temporal artery, ..... 230 

accidents attending, - - . . . gflj 

Eiit-ers. ........ 294 

Boyer's apparatus for fracture of thigi. ... 203 

E:ii-::i = :.i;. ....... 230 

Breast, bandages for the, ..... 101,102 

Brown's bandage for fracture of clavicle, .... 151 



c. 



INDEX. 373 

Canquoin's caustic, ...... 302 

Carpus, bandages for the, - - - . - 115 

dislocations of the, ..... 245 

fractures of, - . . . . . . 181 

Catheterism of the air passages, ..... 353 

of the eustachian tube, ..... 341 

of the large intestine, .... 352 

of the oesophagus, ..... 342 

of the urethra of the female, - - . . 351 

of the male, .... 344 

Cerates, - - . . . . . . 50, 367 

Charpie, ........ 29 

Chest, bandages for the, ...... 98 

Chin, bandages for the, - - . . . -90 

Chlorides of lime and soda, ..... 67 

Chloride of zinc, - - . . . . . 302 

Chloroform, ....... 360 

Clavicle, dislocations of the, ...... 239 

fractures of the, - ..... 147 

Clinical frame, - - - - . . . 137 

Clove-hitch, - - - . . . . - 247 

Compresses, - - - . . . . - 32 

Condyles of humerus, fracture of, - - . . 164 

os femoris, fracture of, - - . . . 210 

Coronoid process of ulna, fracture of, - . . 177 

Cotton, ........ 31 

Croton oil, ....... 297 

Cupping, ........ 282 

Cutaneous irritation, - - . . . . 291 

by rubefacients, .... 292 

by suppurative agents, - . . 300 

by vesicants, - - . . - 294 



Demi-gauntlet, - - - - . . . 115 

Desault's apparatus for fracture of olecranon, . . - 180 

of patella, - . . 216 

of thigh, . . . - 196 

Disinfecting agents, ...... 67 

Dislocations of the bones of the foot, ..... 257 

hand, ... 246 

lower extremity, . . . 249 

runk, .... 238 

32 



374 



INDEX. 



Dislocations of the bones of the upper extremity, - - « 240 

of the clavicle, ..... 238 

of the lower jaw, ..... 237 

compound, ...... 258 

Douche, ........57 

Dressing, general rules for, ..... 52 

apparatus of, - - - . 29 

instruments, ...... 26 

Eighteen-tailed bandage, - - - . . -118 

Electro-puncture, - - - - - 306 

Epididymitis, Fricke's treatment ot, - - - - - 39 

Eustachian tube, catheterism of, - - - - 341 

Extending band, adhesive strips for, - - - - 201 

gaiter for, ----- 197 

handkerchief for, - - - - - 201 

Face, bandages for, - - - - . - 90 

Femur, fractures of, - - . - - - - 185 

Fibula, dislocations of, - . - - - - 256 

fractures of, - - - - - - - 228 

Fingers, bandages for, - - - - - - 115 

dislocations of, ----- - 246 

fractures of, - - - - - - 182 

Forearm, bandages for, - - - - - -112 

dislocations of, - - - - - - 244 

fractures of, - - - - - - 171 

Fox's clavicle apparatus, ------ 149 

Fractures, general considerations on, - - . - 123 

immovable apparatus for, .... 128 

hyponarthecia for, - - - - - 132 

Jenk's apparatus for, ..... 137 

of the bones of the face, - - - - - 139 

of the foot, ...- 232 

of the forearm, - - - - 171 

of the hand, .... 181 

of the head, - - - - - 139 

of the leg, .... 220 

of the pelvis, - - - - - 1 46 

of the shoulder, - - - - 147 

of the trunk, - - - - - 1 43 

of the vertebral column, - - - 143 

of the clavicle, - - - - - -147 



INDEX. 375 

Fractures of the fibula, ------ 228 

of the humerus, ------ 159 

of the lower jaw, ----- 139 

of the os calcis, - - - - - - 232 

of the os femoris, - - - - - 185 

of the patella, ------ 213 

of the radius, - - - - - - 174 

of the ribs, - - - - - - 144 

of the scapula, ----- 153 

of the sternum, - - - - - -144 

of the tibia, ------ 227 

of the ulna, ...... 177 

Fracture-bed, - - - - - -- 135 

Fracture-box,- - - - - - - - 222 

Fumigations, - - - - „ . . 66 



Gaiter, laced, ....... 121 

for extension in fracture of thigh, - - - 197 
Gauntlet, - - - - - - - -115 

Gerdy's bandage for fracture of patella, - - - - 216 

Gibson's bandage for fracture of lower jaw, - - - - 140 

modification of Hagedorn's splint, ... 205 

Granville's lotions, ------- 299 

Groin, bandages for the, ------ 106 

Guillou's novel method of treating fracture of clavicle, - - 152 

Gun-cotton, a solution of, for adhesive strips, - - - 333 



Hand, bandages for, - - - - - - -115 

dislocations of bones of, - -- - - - 246 

fractures of bones of, ------ 181 

Hare-lip, twisted suture for, - - - - - 337 

Head, bandages for, ---...-85 

fractures of bones of, - - - - - 139 

Haemorrhage, arrest of, - - - - - 309 

by astringents, - - - - 310 

by cauterization, - - - .311 

by cold applications, - - - 309 

by the ligature, - - - 321 

by matico, - - - - 311 

b y plugging, - - - - - 320 

by pressure with the hand, - - 314 



37fi 



::."izx. 



H?ri::::i:rr. orres: ::". ;t t:rs:cr., ..... 321 

"17 :_r :.:-:ri:-r% - - - 5".-: 

mm 10 e rose. . . . _ 326 

fr:ro. ±e re:::o~. .... 33} 

H::-;::-:, 3;s!::o:::::s ::",.---_.-_ MS 

Kuif:;:. iisiooetirns :f. ..... C4J 

fri :._:;= ::. - - - . . . 159 



Ir.n:vi:".e e"in:os ::: frocou-res. .... 1C 5 

Izolfoei rlire :":: rro.:7ores ::" fif fofri. .... 189 

:":: fnrrores ::" :ie ^:, .... CC5 

I:."r::i:^s. ~:ifs ::ki~3iis:erizr, - 354 

:: liclrrni". cu:L ... . . . 355 

bj ±e r-— , ........ 354 

c:±e— e— e, 35? 

c£ ±z i'..z7zs, 351 

crtie-ri^, 357 

Losrr; merle :":: :':; - ofeer-crse. - - - . -25 

I-Tir— r.ei berorg-e ::: ~e Li?. - .... }3 

:':: I :r: giro. fir. of w: ■_ r. f = . - - - 33-5 

for orooosvorso w-.zz.i5. ■ - - 33} 

•L-.-i- . - " * ■ - - • DO 

Isircfms sol ester. 4! 

Issues. 303 



J:-,:::.:::-;::, 87 

c3Ls3cce"f oris of lower. ...... 237 

freoooores of lower. .-.--. 13} 

Jerks" eeoereoois. ....... 137 

Jirr's 10 per ins for wrv.roeck. - - - ■ - 37 

Jugular vein, bleeding from, ...... 274 

J-"'~=. oreiiooer: oforootores 0: tie leg wifr. - - . 331 

Joro-oors 3:: i'i:::ire if-.firi. ..... 1}5 



115 

335 
213 



Lachrymal duct, injection o£ ..... 333 

Leiooe^for fleeoir.l:.. '26$ 



INDEX. 377 

Leeches, preservation of, - - - - - - 288 

Leeching, ........ 285 

Leg, bandages for, - - - - - - 119 

dislocations of, - - - - - - - 255 

fractures of, ...... 220 

Ligature for the arrest of haemorrhage, .... 321 

Liniments, ....... 50, 369 

Lint, preparation and uses of, - - - - 29 

Lotions, ....-..- 49, 365 



M. Le Doyen's disinfectant, ...... 69 

Mayor and Sauter, clinical frame of, - - - 137 

hyponarthecia for the arm of, - 173 

for the leg of, - - - 230 

Moxa, preparation and application of the, .... 302 

Neck and axilla, bandages for the, ... 95, 100, 111 

Nitrate of silver, - - - - - - - 301 

Nose, bandages for the, ...... 92 

fractures of the bones of the, - - - 139 

Nostrils, arrest of bleeding from the, - . - - 326 



Ointments, ....... 50, 368 

4. 
Patella, dislocations of the, ...... 255 

fractures of the, - - - - - - 213 

Penis, bandages for the, - - - - 110, 350 

Pennsylvania Hospital, treatment of fractures of clavicle in the, - 150 

of thigh in the, - 197 

of leg in the, - 222 

Pelvis, bandages for, - - - - - - -105 

dislocations of, - - , - - - 238 

fractures of, - - - - - - 146 

Phlebotomy, ....... 262 

Physick's splints for fracture of thigh, - - 197 

Plasters, -------- 41 

Potassa, ..--.... 301 

Poultices, ....... 42 

Pulleys for reduction of dislocations, ... - - 242 

Purse of Pibrac for the tongue, - - - - 94 



378 ixdex. 

Radius, dislocations of the, ..... 244 

fractures of the, ...... 174 

Ribs, dislocations of the, ...... 238 

fractures of the, ...... 144 

Roller, the, ....... 71 



Sailor's knot, ....... 323 

Scapula, fractures of the, - - - - - -153 

Scultetus' bandage, ...... 80 

Setons, - - - - . . . .304 

Seton-needle, ....... 304 

Sinapisms, ........ 292 

Spanish windlass, ...... 319 

Splints of A mesbury, ..... 192,207 

Boyer, ...... 203 

Desault, ...... 180, 196, 216 

Dupuvtren, ...... 175, 228 

Gibson, - - - - - - - 205 

Hagedorn, - - - - - - 206 

Hutchinson, - - - - - .225 

Liston, ...... 204,226 

Lonsdale, 142, 161, 172, 217 

Mayo, ....... 1G9 

Mutter, ....... 259 

Neville, 222 

Physick, 197 

Smith, N. R., 195 

Sponge, preparation and uses of the, - - - - 51 

Sponge-tent, ....... 35 

Sternum, fractures of the, ...... 144 

Stomach, catheterism of the, - - - - 342 

Suture, the continued, ... ... 335 

the dry, ....... 337 

the interrupted, ...... 333 

the quilled, ...... 335 

the twisted, ....... 337 



Tarsus, dislocations of the bones of the, .... 257 

fractures of the bones of the, .... 232 

Tartar emetic, - - - - - - - 300 



INDEX. 



379 



Torsion, 

Tourniquet, 

Tow, 



321 

316 

32 



Urethra, catheterism of the, 
injections of the, 



344 
357 



Vaccination, - 

Vaccine virus, preservation of, 

Vagina, injections by the, 

Vapours of ether and chloroform, 

Venesection, - 

Veins of the arm, anatomy of the, 

Vertebrce, fractures of the, 

dislocations of the, - 
Vesicants, ... 

Vienna paste, 



306 
306 
357 
360 
262 
262 
143 
238 
294 
302 



Wounds, means of promoting the closure of, 

dressing of, - 
Water, applications of, to surgical purposes, 



332 

330 

54 



Appendix of formulae, 



365 



THE END. 



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